Southwest Healthcare Rancho Springs Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to ensure patient safety for two of 21 sample patients (Patients 1 and 12), when: 1. For Patient 1, spinal precautions (efforts to prevent movement of the bones of the spine like c-collar, cervical collar, a device to support, stabilize, and immobilize the neck) was not ordered immediately, and nursing assessments and reassessments were not completed; and 2. For Patient 12, the facility did not notify the Family Member (FM) 1 of admission to the facility on a 5150 (a short term involuntary hold to evaluate if a patient is a danger to themselves, danger to others or unable to care for oneself) hold. These failures had the potential to result in paralysis (unable to move certain parts of the body) and death for Patient 1 and for Patient 12, these failures resulted in the FM not being informed with a potential to cause patient harm. Findings: 1. On February 24, 2026, at 1 p.m., a review of Patient 1’s medical record was conducted with the Clinical Systems Analyst (CSA). An undated facility document titled, “Face Sheet,” was reviewed. The document indicated, “...[Name of Patient 1]...ADM [Admit] DATE...01/02/2026 [January 2, 2026]...TIME...2000 [8 p.m.]...ADM DIAGNOSIS [the process of identifying a disease, condition, or injury]....CERVICAL STENOSIS [the narrowing of the spinal canal in the neck] OF THE SPINE...” An undated facility document titled, “Triage [a medical process used to assess and prioritize patients in emergency situations] Note,” was reviewed. The document indicated, “...Triage Note...SERVICE DATE/TIME:...1/2/2026 16:21 [4:21 p.m.]...” A facility document titled, “ED [Emergency Department, a unit for patients with emergency conditions] Physician Record,” dated January 2, 2026, was reviewed. The document indicated, “...1/02/2026 1644 [4:44 p.m.]...Chief Complaint...sent by [Medical Doctor (MD) 1] for admission for planned neurosurgery. Pt [Patient] complaint of tingling of left side of body and in right leg...presents to the Emergency Department for worsening paresthesias [a sensation of tingling, burning, or numbness on the skin]...Patient reports tingling now radiating down to my toes and head,”with involvement of right and left sides...Patient notes intermittent left leg weakness...” A facility document titled, “History & Physical,” dated January 2, 2026, was reviewed. The document indicated, “...Result Date: January 02, 2026 20:06 [8:06 p.m.]...Pt [Patient] complaint of tingling of left side of body and in right leg...Patient Initially presented to the [facility B] and was admitted on 12/31/2025 [December 31, 2025], had MRI [Magnetic Resonance Imaging, an imaging test that uses strong magnetic fields and radio waves to produce images of organs and bones] of the C- spine [cervical spine, the neck] which showed severe central stenosis [critical narrowing of the main passageway holding the spinal cord (along thin bundle of tissues that extend from the brain to the lower back)] with cord compression [a serious medical condition where pressure is applied to the spinal cord]...Review of Systems...left leg weakness...Physical exam...c-collar intact...left lower extremity strength is about 3 out 5 [3 out of 5 strength means patient can move their limb but cannot withstand any, or only minimal, resistance from an examiner]...” A facility document titled, “Informed Consent Permission Form,” dated January 5, 2026, was reviewed. The document indicated, “...[Name of Patient 1]...Date: 01/05/2026 [January 5, 2026]...My healthcare provider recommended the procedure...This form helps me learn about the procedure and what could go well or go poorly...the procedure is called...Fusion spine cervical posterior [a surgery through the back of the neck to stabilize the cervical spine]...I give my permission...Patient’s (or patient’s decision maker’s) Print name/signature...[Signature of Patient 1]....” A facility document titled, “Operative Reports,” dated January 5, 2026, was reviewed. The document indicated, “...Result Type:...Result Date: January 05, 2026 19:36 [7:36 p.m.]...Post Operative [after operation] note...Preoperative [before operation] Diagnosis...Cervical Stenosis...cord compression...Operation...Posterior cervical decompressive laminectomy [a surgery done from the back of the neck to relieve pressure on the spinal cord or nerves]...” During the review of Patient 1’s medical record there was no documented evidence spinal precautions or c-collar was ordered immediately for Patient 1 by MD 2 in the Emergency Department. On February 25, 2026, at 10:02 a.m., an interview with the CSA was conducted. The CSA stated there were no orders placed for spinal precautions or c-collar for Patient 1 by MD 2. On February 25, 2026, at 2:30 p.m., an interview with the Emergency Department Medical Director (EDMD) was conducted. The EDMD stated the dangers of cord compression are paralysis and loss of function for the arms or legs or both depending on where the cord compression is. The EDMD stated MD 2 did not place an order for spinal precautions or c-collar for Patient 1. The EDMD stated MD 2 should have ordered spinal precautions or c-collar immediately. During the review of Patient 1’s medical record there was no documented evidence a nursing assessment and reassessments were completed in the ED. On February 25, 2026, at 9 a.m., an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated Patient 1 had a complaint of spinal stenosis. RN 1 stated the risks for spinal stenosis is “impingement [Squeezed] of the spinal cord, if not addressed it can lead to loss of sensation, paralysis and death.” RN 1 stated there were no initial nursing assessment and reassessments completed for Patient 1 in the ED. RN 1 stated the nurses should have assessed and reassessed Patient 1. RN 1 stated it is important to do assessments and reassessments in the ED, “things change, it is how you recognize a life or limb threat.” On February 27, 2026, at 10:51 a.m., an interview with the ED Director (EDD) was conducted. The EDD stated it is important to do an initial nursing assessment, “it is baseline. It guides their care, to know what to do and what to treat.” The EDD stated it is important to do reassessments, “to monitor patient status, things change for patients.” A facility policy and procedure titled, “Patient Rights,” dated August 25, 2022, was reviewed. The policy indicated, “...Purpose: To establish guidelines to ensure that patients are informed of their rights and responsibilities regarding their care, treatment, and services and to assist patients in exercising their rights...Patient Rights...You have the right to...Considerate And respectful care, and to be made comfortable...Receive care in a safe setting...” A facility policy and procedure titled, “Cervical Spine Precaution,” dated June 27, 2019, was reviewed. The policy indicated, “...Purpose: To establish guidelines to initiate or discontinue cervical spinal precautions in a timely manner...A rigid cervical collar shall be applied and maintained in all patients when a spinal injury is suspected, based on a blunt traumatic mechanism and any of the following: 1. Focal [localized] neurologic deficit [an impairment of the body’s nervous system function caused by injury or disease in the brain, spinal cord, or nerves] such as limb paralysis, weakness, or numbness...” A policy and procedure titled, “ED: Assessment and Reassessment Guidelines,” dated October 26, 2023, was reviewed. The policy indicated, “...purpose:...To provide guidance to the ED nursing team regarding the Frequency and intensity of patient assessment and reassessment...assessments should be done more frequently based on the condition and acuity [severity of illness] of the patient...assessment and reassessments are initiated by the triage RN and continue throughout the patients ED stay...” 2. On February 24, 2026, at 10 a.m., a review of Patient 12’s medical record was conducted with the Quality Registered Nurse (QRN). It indicated Patient 12 arrived at the ED on February 11, 2026, for Suicidal Ideation (SI, having thoughts, ideas, or preoccupations about ending one’s own life). A review of the facility document titled, “ED Physician Record,” dated February 11, 2026, at 9:37 p.m., authored by Physician (MD) 5, was reviewed. The document indicated, “...The patient presents with suicidal ideation. 14 y/o [year old] w/ [with] hx [history] ADHD, [attention deficit disorder, a mental disorder with symptoms of not being able to keep focus, excessive movements not fitting to the setting and impulsivity) BIBA [brought in by ambulance] from Facility C for SI. P [Patient 12] was placed on a 5150 hold in the field by [Name of City] PD [police department].per EMS [Emergency Medical Services, a system that responds to emergencies in need of highly skilled prehospital clinicians], she [Patient 12] called the suicide hotline and told him that she had placed a belt around her neck and lifted over something and then sat on the bed...” A review of an untitled facility document, dated February 11, 2026, at 8:49 p.m., was conducted. The document indicated, “...Contact Information Nearest Relative Name [Name of Family Member (FM) 1...Emergency Contact Name [name of FM 1]...Admitting information date 02/11/2026 [February 11, 2026] Time 2049 [8:49 p.m.]...” There were no documented evidence FM 1 was notified of Patient 12’s admission. On February 24, 2026, at 9:37 a.m., an interview was conducted with Case Manager (CM) 5. CM 5 stated he spoke with Patient 12 on admission and he did not call the family member after his visit. CM 5 stated a call should have been made to the family member to inform of the admission, and it is everyone’s responsibility to update the family especially for a minor. On February 25, 2026, at 10 a.m., an interview was conducted with the Director of Social Services (DSS). The DSS stated, the family member should be updated and involved if they are the legal guardian. A review of the facility’s policy and procedures titled, “Patient’s Rights and Responsibilities,” dated August 25, 2022, was conducted. The policy indicated, “...[Name of Facility] believes the basic rights of human beings for independence of expression, decision, action, and concern for personal dignity in human relationships are of great importance. Thus, one of the hospital’s prime responsibilities is to ensure that patient’s rights are preserved, including the rights of neonates, children, adolescents, and geriatric patients...””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to ensure the medical staff are accountable for the medical care they provide to the patients for one of 21 patients (Patient 1) reviewed, when an order for cervical spine precautions was not placed. This failure had the potential to result in paralysis (unable to move certain parts of your body) for Patient 1. Findings: On February 24, 2026, at 1 p.m., a review of Patient 1’s medical record was conducted with the Clinical Systems Analyst (CSA). An undated facility document titled, “Face Sheet,” was reviewed. The document indicated, “...[Name of Patient 1]...ADM [Admit] DATE...01/02/2026 [January 2, 2026]...TIME...2000 [8 p.m.]...ADM DIAGNOSIS [the process of identifying a disease, condition, or injury]...CERVICAL STENOSIS [the narrowing of the spinal canal in the neck] OF THE SPINE...” An undated facility document titled, “Triage (a medical process used to assess and prioritize patients in emergency situations) Note,” was reviewed. The document indicated, “...Triage Note...SERVICE DATE/TIME:...1/2/2026 16:21 [4:21 p.m.]...” A facility document titled, “ED [Emergency Department, a unit for patients with emergency conditions] Physician Record,” dated January 2, 2026, was reviewed. The document indicated, “...1/02/2026 1644 [4:44 p.m.]...Chief Complaint...sent by [Medical Doctor (MD)] 1 for admission for planned neurosurgery. Pt [Patient] complaint of tingling of left side of body and in right leg...presents to the Emergency Department for worsening paresthesias [a sensation of tingling, burning, or numbness on the skin]...Patient reports tingling now radiating down to my toes and head,”with involvement of right and left sides...Patient notes intermittent left leg weakness...” A facility document titled, “History & Physical,” dated January 2, 2026, was reviewed. The document indicated, “...Result Date: January 02, 2026 20:06 [8:06 p.m.]...Pt [Patient] complaint of tingling of left side of body and in right leg...Patient Initially presented to the [facility B] And was admitted on 12/31/2025 [December 31, 2025], had MRI [Magnetic Resonance Imaging, an imaging test that uses strong magnetic fields and radio waves to produce images of organs and bones] of the C- spine [cervical spine, the neck] which showed severe central stenosis [there is critical narrowing of the main passageway holding the spinal cord (along thin bundle of tissues that extend from the brain to the lower back)] with cord compression [a serious medical condition where pressure is applied to the spinal cord]...Review of Systems...left leg weakness...Physical exam...c-collar intact...left lower extremity strength is about 3 out 5 [3 out of 5 strength means patient can move their limb but cannot withstand any, or only minimal, resistance from an examiner]...” A facility document titled, “Informed Consent Permission Form,” dated January 5, 2026, was reviewed. The document indicated, “...[Name of Patient 1]...Date: 01/05/2026 [January 5, 2026]...My healthcare provider recommended the procedure...This form helps me learn about the procedure and what could go well or go poorly...the procedure is called...Fusion spine cervical posterior [a surgery through the back of the neck to stabilize the cervical spine]...I give my permission...Patient’s (or patient’s decision maker’s) Print name/signature...[Signature of Patient 1]....” A facility document titled, “Operative Reports,” dated January 5, 2026, was reviewed. The document indicated, “...Result Type:...Result Date: January 05, 2026 19:36 [7:36 p.m.]...Post Operative [after operation] note...Preoperative [before operation] Diagnosis...Cervical Stenosis...cord compression...Operation...Posterior cervical decompressive laminectomy [a surgery done from the back of the neck to relieve pressure on the spinal cord or nerves]...” There were no documented evidence spinal precautions or c-collar was ordered for Patient 1 by MD 2 immediately after patient examination in the Emergency Department. On February 25, 2026, at 10:02 a.m., an interview with the CSA was conducted. The CSA stated there were no orders placed for spinal precautions or c-collar for Patient 1 by MD 2. On February 25, 2026, at 2:30 p.m., an interview with the Emergency Department Medical Director (EDMD) was conducted. The EDMD stated the dangers of cord compression are paralysis and loss of function for the arms or legs or both depending on where the cord compression is. The EDMD stated that MD 2 did not place any order for spinal precautions or c-collar for Patient 1. The EDMD stated MD 2 should have ordered spinal precautions or c-collar immediately. A facility policy and procedure titled, “Patient Rights,” dated August 25, 2022, was reviewed. The policy indicated, “...Purpose: To establish guidelines to ensure that patients are informed of their rights and responsibilities regarding their care, treatment, and services and to assist patients in exercising their rights...Patient Rights...You have the right to : 1. Considerate And respectful care, and to be made comfortable...Receive care in a safe setting...” A facility policy and procedure titled, “Cervical Spine Precaution,” dated June 27, 2019, was reviewed. The policy indicated, “...Purpose: To establish guidelines to initiate or discontinue cervical spinal precautions in a timely manner...A rigid cervical collar shall be applied and maintained in all patients when a spinal injury is suspected, based on a blunt traumatic mechanism and any of the following: 1. Focal [localized] neurologic deficit [an impairment of the body’s nervous system function caused by injury or disease in the brain, spinal cord, or nerves] such as limb paralysis, weakness, or numbness ...” A facility document titled, “Governing Board Bylaws,” dated August 24, 2023, was reviewed. The document indicated, “...The Board shall require that the Medical Staff and other professional staffs contribute to assessment and continuous improvement of patient care quality, and establish and implement the following policies, procedures and practices...Each patient’s medical conditions shall be the responsibility of a physician member of the medical staff...” A facility rules and regulations titled, “Medical Staff Rules and Regulations,” dated January 25, 2024, was reviewed. The document indicated, “...Responsibility...The patients attending physician shall be responsible for directing and supervising the patients overall care...Transfer of care to the attending physician by the Emergency Department physician occurs when either: a) the Emergency Department physician and admitting physician have collaborated...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50304 hyBased on interview and record review, the facility failed to implement its policies and procedures for two of 21 sample patients (Patients 1, and 4 ), when: 1. For Patient 1, an initial nursing assessment and reassessments were not completed in the Emergency Department (ED, a unit for patients with emergency conditions); and 2. For Patient 4, the patient’s saline lock (a thin, flexible, short catheter inserted into a vein in the hand or arm that provides immediate access for medication or fluids) was observed not having an alcohol cap (a small, device containing alcohol that twists into the injection site [where nurses inject medications, fluids, or flushes directly into the line] or directly on an intravenous [IV, within the vein] catheter to clean them and prevent infections) on the injection site. These failures had the potential to delay treatment, worsen patient’s condition, or cause infection. Findings: 1. On February 24, 2026, at 1 p.m., a review of Patient 1’s medical record was conducted with the Clinical Systems Analyst (CSA). An undated facility document titled, “Face Sheet,” was reviewed. The document indicated, “...[Name of Patient 1]...ADM [Admit] DATE...01/02/2026 [January 2, 2026]...TIME...2000 [8 p.m.]...ADM DIAGNOSIS [the process of identifying a disease, condition, or injury]...CERVICAL STENOSIS [the narrowing of the spinal canal in the neck] OF THE SPINE...” An undated facility document titled, “Triage [a medical process used to assess and prioritize patients in emergency situations] Note,” was reviewed. The document indicated, “...Triage Note...SERVICE DATE/TIME:...1/2/2026 16:21 [4:21 p.m.]...” A facility document titled, “ED Physician Record,” dated January 2, 2026, was reviewed. The document indicated, “...1/02/2026 1644 [4:44 p.m.]...Chief complaint...sent by [Medical Doctor (MD)] 1 for admission for planned neurosurgery. Pt [Patient] complaint of tingling of left side of body and in right leg...presents to the Emergency Department for worsening paresthesias [a sensation of tingling, burning, or numbness on the skin]...Patient reports tingling now radiating down to my toes and head,”with involvement of right and left sides...Patient notes intermittent left leg weakness...” A facility document titled, “Informed Consent Permission Form,” dated January 5, 2026, was reviewed. The document indicated, “...[Name of Patient 1]...Date: 01/05/2026 [January 5, 2026]...My healthcare provider recommended the procedure...This form helps me learn about the procedure and what could go well or go poorly...the procedure is called...Fusion spine cervical posterior [a surgery through the back of the neck to stabilize the cervical spine]...I give my permission...Patient’s (or patient’s decision maker’s) Print name/signature...[Signature of Patient 1]....” A facility document titled, “Operative Reports,” dated January 5, 2026, was reviewed. The document indicated, “...Result Type:...Result Date: January 05, 2026 19:36 [7:36 p.m.]...Post Operative [after operation] note...Preoperative [before operation] Diagnosis...Cervical Stenosis...cord compression...Operation...Posterior cervical decompressive laminectomy [a surgery done from the back of the neck to relieve pressure on the spinal cord or nerves]...” There were no documented evidence an initial nursing assessment and reassessments were completed in the ED. On February 25, 2026, at 9 a.m., an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated there were no initial nursing assessment and reassessments completed for Patient 1 in the ED. RN 1 stated the nurses should have assessed and reassessed Patient 1. RN 1 stated it is important to do assessments and reassessments in the ED, “things change, it is how you recognize a life or limb threat.” On February 27, 2026, at 10:51 a.m., an interview with the ED Director (EDD) was conducted. The EDD stated it is important to do an initial nursing assessment, “it is baseline. It guides their care, to know what to do and what to treat.” The EDD stated it is important to do reassessments, “to monitor patient status, things change for patients.” A policy and procedure titled, “ED: Assessment and Reassessment Guidelines,” dated October 26, 2023, was reviewed. The policy indicated, “...Purpose:...To provide guidance to the ED nursing team regarding the Frequency and intensity of patient assessment and reassessment...assessments should be done more frequently based on the condition and acuity [severity of illness] of the patient...assessment and reassessments are initiated by the triage RN and continue throughout the patients ED stay...” 2. On February 23, 2026, at 1:19 p.m., a tour of the Emergency Room (ER) was conducted. Patient 4’s saline lock was observed to not have an alcohol cap. The Director of Emergency Room (DER) verified there was no alcohol cap on Patient 4’s saline lock. On February 23, 2026, at 1:19 p.m., an interview was conducted with the DER. The DER stated there’s no alcohol cap on the saline lock. The DER stated they usually put an alcohol cap on. On February 26, 2026, at 11:36 a.m., an interview was conducted with the Director for Infection Prevention (DIP). The DIP stated the nurses should be putting on alcohol caps and changing them. The DIP stated it is important to put alcohol caps on injection sites “to minimize the risk of cross contamination with the environment and infection.” A policy and procedure titled, “Intravenous [IV, within the vein] therapy [a medical process that administers fluids, medications and nutrients directly into a person’s vein],” dated October 27, 2022, was reviewed. The document indicated, “...PURPOSE: To provide consistent, safe and clear guidelines for intravenous IV therapy within each licensed nurses scope of practice...Peripheral IV Catheter Cap Changes...Peripheral IV catheter caps will be changed when the IV is restarted or whenever it is expected that the cap has been compromised...””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to ensure a safe discharge (when a patient is allowed to leave a hospital after treatment) was facilitated for one of 21 sample patients (Patient 1), when home health (a variety of health care services that is provided to patient’s home after discharge from the hospital) service was not ordered prior to Patient 1’s discharge. This failure had the potential to delay Patient 1’s recovery and may impact her condition. Findings: On February 24, 2026, at 1 p.m., a review of Patient 1’s medical record was conducted with the Clinical Systems Analyst (CSA). An undated facility document titled, “Face Sheet,” was reviewed. The document indicated, “...[Name of Patient 1]...ADM [Admit] DATE...01/02/2026 [January 2, 2026]...TIME...2000 [8 p.m.]...ADM DIAGNOSIS [the process of identifying a disease, condition, or injury]....CERVICAL STENOSIS [the narrowing of the spinal canal in the neck] OF THE SPINE...” A facility document titled, “History & Physical,” dated January 2, 2026, was reviewed. The document indicated, “...Result Date: January 02, 2026 20:06 [8:06 p.m.]...Pt [Patient] complaint of tingling of left side of body and in right leg...Patient Initially presented to the [Facility B] And was admitted on 12/31/2025 [December 31, 2025], had MRI [Magnetic Resonance Imaging, an imaging test that uses strong magnetic fields and radio waves to produce images of organs and bones] of the C- spine [cervical spine, the neck] which showed severe central stenosis [there is critical narrowing of the main passageway holding the spinal cord (along thin bundle of tissues that extend from the brain to the lower back)] with cord compression [a serious medical condition where pressure is applied to the spinal cord]...Review of Systems...left leg weakness...Physical exam...c-collar intact...left lower extremity strength is about 3 out 5 [3 out of 5 strength means patient can move their limb but cannot withstand any, or only minimal, resistance from an examiner]...” A facility document titled, “Informed Consent Permission Form,” dated January 5, 2026, was reviewed. The document indicated, “...[Name of Patient 1]...Date: 01/05/2026 [January 5, 2026]...My healthcare provider recommended the procedure...This form helps me learn about the procedure and what could go well or go poorly...the procedure is called...Fusion spine cervical posterior [a surgery through the back of the neck to stabilize the cervical spine]...I give my permission...Patient’s (or patient’s decision maker’s) Print name/signature...[Signature of Patient 1]....” A facility document titled, “Operative Reports,” dated January 5, 2026, was reviewed. The document indicated, “...Result Type:...Result Date: January 05, 2026 19:36 [7:36 p.m.]... Post Operative [after operation] note...Preoperative [before operation] Diagnosis...Cervical Stenosis...cord compression...Operation...Posterior cervical decompressive laminectomy [a surgery done from the back of the neck to relieve pressure on the spinal cord or nerves]...” A facility document titled, “Discharge Planning Assessment,” authored by Registered Nurse (RN) 2, dated January 3, 2026, was reviewed. The document indicated, “...Discharge planning I...discharge plan will depend on hospital course as surgery is anticipated...Post Discharge Arrangement...Post Acute Setting [a place where a patient receives care to recover after leaving the hospital]...Discharge to, Anticipated: Home with home health...” A facility document titled, “Progress Note-Physician,” dated January 8, 2026, was reviewed. The document indicated, “...Author: Name of NP (Nurse Practitioner, a nurse who has advanced education and training)]...Verified By: [Name of MD 1]...Patient is a 45 -year-old female...with left-sided weakness...Plan...Diagnoses [the identification of the specific disease, or health condition of a patient]...1. Cervical Stenosis of spine...Discharge planning:...Discharge To, Anticipated: Home with home health...Electronically signed On: 01.09.2026 [January 9, 2026] 14:04 [2:04 p.m.]...[Name of MD 1]...” A facility document titled, “Discharge Summary,” dated January 8, 2026, was reviewed. The document indicated, “...Verified By: [Name of MD 4]...Discharge Diagnosis...Cervical stenosis of spine...Discharge request...01/08/2026...Home routine...” There was no documented evidence a discharge with home health was ordered for Patient 1. On February 24, 2026, at 2:03 PM, an interview with the CSA was conducted. The CSA stated there was no order for home health for Patient 1 prior to discharge. The CSA stated it should have been ordered, “based on the note by the NP.” On February 24, 2026, at 2:24 p.m., an interview with the Director of Care Coordination (DCC), was conducted. The DCC stated case managers coordinate the home health placement of patients. The DCC stated the case managers are aware of the patient’s needs for home health placement from the multidisciplinary rounds (daily meetings where a patient’s entire care team including doctors, nurses, pharmacists, and case managers gather to discuss and update the treatment plan) they participate in. The DCC stated the case manager will ask for an order from the doctor for home health “and if they don’t get it they will ask the bedside nurse to reach out to the doctor as well.” The DCC stated it is the responsibility of the case manager to follow up on the orders of the physician to get authorization for services. The DCC stated “they have to have the order.” On February 25, 2026, at 1:09 p.m., an interview with RN 2, was conducted. RN 2 stated case managers are aware of the plan for patients. RN 2 stated it is their responsibility to make sure the discharge plan is safe for the patient and arrangements were made prior to patient discharge. RN 2 stated “the case manager should have questioned the doctor’s discharge order” of routine home discharge for Patient 1. On February 27, 2026, at 9:26 a.m., an interview was conducted with MD 1. MD 1 stated the plan was for Patient 1 to go home with home health. MD 1 stated he approved the plan for home health documented by the NP. MD 1 stated home health is important, “It is for patient safety...and advices are given to patients to prevent falls.” A facility policy and procedure titled, “Discharge Planning,” dated January 24, 2019, was reviewed. The policy indicated, “...Discharge planning is initiated upon admission, to all patients admitted to the hospital. The RN assesses the patients on admission, initiates the discharge planning assessment and is risk screened for discharge planning needs...Assessments (evaluation) take into consideration the patients immediate and emerging needs, long term care needs physiological, psychological, social and cultural concerns. The continuity of care is of primary concern...The case management department (case managers, and social workers) are the responsible personnel with a comprehensive knowledge and experience in discharge planning...The Care Coordinator/Social Worker [trained professionals are devoted to helping vulnerable people and communities] will collaborate with representatives of the hospital administration, the medical staff, nursing and other departments involved in patient care when assessing, planning and implementing the discharge plan...Patients will be discharged based upon attainment of patient care goals as evident in the interdisciplinary plan of patient care...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to implement their policies and procedures (P&P) for four of 24 patients (Patients 2, 12, 14, and 21), when: 1. For Patients 2, 12, and 21, the Important Message from Medicare (IMM-a mandatory notice hospitals give to admitted Medicare patients, informing them of their crucial right to appeal a hospital discharge decision, explaining the “fast appeal” process, and detailing their financial protections, ensuring they know they won’t be charged for continued care during a timely appeal) was not given to the patient upon admission and/or prior to discharge; and 2. For Patient 14, the Conditions of Admission (CoA, the contract terms patients sign, outlining financial, consent, and service understandings, covering patient rights and responsibilities like paying bills and agreeing to treatment) was not given to the patient upon admission. This failure had the potential for the patients to not be informed of their rights as an admitted patient, and may fail to exercise their rights prior to discharge. Findings: 1a. On December 19, 2025, at 9:20 a.m., a review of Patient 2’s medical record was conducted with the Quality Nurse (QN) 1. The facility document titled, “Face Sheet,” dated, September 21, 2025, at 3:44 a.m., was reviewed. The document indicated, “...Insurance Information...MEDICARE PART A...” The facility document titled, “History and Physical,” dated September 21, 2025, at 3:48 p.m., authored by Medical Doctor (MD) 1 was reviewed. The document indicated Patient 2 was admitted to the facility for a fall and near syncope (feeling like you’re about to faint or pass out but not actually losing consciousness). Patient 2 had a medical history of blindness (inability to see with eyes), depression (a serious, common mood disorder causing persistent sadness and loss of interest), hypertension (high blood pressure), and anxiety (a natural feeling of unease, worry, or fear about what might happen). During the review of Patient 2’s medical record with the QN, there was no documented evidence of a completed IMM upon admission and prior to discharge. The facility document titled, “Discharge Summary,” dated, September 24, 2025, at 2:46 p.m., authored by MD 4 was reviewed. The document indicated Patient 2 was discharged to an acute rehabilitation facility (a facility that provides intensive, hospital-level therapy for people recovering from serious illness or injury). 1b. On December 19, 2025, at 9:20 a.m., a review of Patient 12’s medical record was conducted with the QN 1. The facility document titled, “Face Sheet,” dated, December 16, 2025, at 8:32 a.m., was reviewed. The document indicated, “...Insurance Information...MEDICARE PART A...” The facility document titled, “History and Physical,” dated, December 16, 2025, at 8:30 a.m., was reviewed. The document indicated Patient 12 was admitted to the facility for syncopal episodes (a sudden, temporary loss of consciousness (fainting) due to a brief lack of blood flow and oxygen to the brain) and bradycardia (heartrate of less than 60 beats per minute). Patient 12 had a medical history of bladder cancer (when abnormal cells in the bladder lining grow uncontrollably, forming tumors) and complete heart block (a severe heart rhythm problem where electrical signals from the upper to lower heart chambers are totally blocked, making them beat independently and often too slowly, limiting the heart’s ability to pump blood, causing dizziness, fainting, and shortness of breath, and is a potentially life-threatening condition). During the review of Patient 12’s medical record with the QN, there was no documented evidence of a completed IMM prior to Patient 12’s discharge. The facility document titled, “Discharge Summary,” dated, December 21, 2025, at 5:36 p.m., authored by MD 5 was reviewed. The document indicated Patient 12 was discharged home. 1c. On December 19, 2025, at 9:20 a.m., a review of Patient 21’s medical record was conducted with the QN 1. The facility document titled, “Face Sheet,” dated, November 11, 2025, at 8:25 a.m., was reviewed. The document indicated, “...Insurance Information...MEDICARE HMO...” The facility document titled, “History and Physical,” dated, November 11, 2025, at 2:10 p.m., was reviewed. The document indicated, Patient 21 was admitted to the facility for sepsis (a life-threatening medical emergency where the body’s extreme, overactive response to an infection damages its own tissues and organs, leading to inflammation, potential organ failure). Patient 21 had a medical history of dementia (a severe decline in mental abilities) and rectal cancer (cancer that starts in the cells of the rectum, the last section of the large intestine). During the review of Patient 21’s medical record with the QN there was no documented evidence of a completed IMM upon Patient 21’s admission. The facility document titled, “Discharge Summary,” dated, November 13, 2025, at 11:18 a.m., authored by MD 6 was reviewed. The document indicated Patient 21 was discharged to hospice (a specialized care approach for people with serious illnesses, focusing on comfort, quality of life). On December 22, 2025, at 2 p.m., an interview was conducted with the Director of Patient Access and Registration (DPA). The DPA stated, “...The IMM requirement is if a patient is admitted as an inpatient and is a Medicare patient, patient access is responsible for the first admission IMM...should be done within 48 hours of admission, if able to get from the patient. If it wasn’t done, they would continue to make attempts to obtain the IMM with the patient or family...it should have been done on admission...” On December 23, 2025, at 11:15 a.m., an interview was conducted with the Director of Case Management (DCM). The DCM stated, “...Case management is responsible for the IMM upon discharge...the IMM is supposed to be administered to every Medicare patient within 4 hours prior to discharge or within 48 hours prior to discharge...it should have been done prior to discharge...” A review of the facility policy and procedure (P&P) titled, “Important Message from Medicare,” revised April 24, 2025, was conducted. The P&P indicated, “...The initial IMM will be delivered to all Medicare/Medicare Advantage/HMO inpatients...at the time of admission (or no later than 2 calendar days following admission)...The follow up IMM must be delivered...as far in advance of discharge as possible, but not more than 2 calendar days before the planned date of discharge...When the discharge date cannot be predicted in advance, the follow up IMM may be delivered on the day of discharge; however, the beneficiary/representative must be allowed at least 4 hours to consider appealing the discharge decision...” 2. On December 22, 2025, at 9 a.m., Patient 14’s medical record was reviewed with the Senior Clinical Analyst (SCA). The document titled “History and Physical,” dated March 24, 2025, at 12:09 p.m., indicated Patient 14 had a past medical history of “...CAD [Coronary Artery Disease-Arteries that supply blood to the heart become narrowed or blocked], cardiac stent [small mesh tube that a doctor places inside a heart artery to hold it open so blood can flow more easily to the heart muscle] x 2 [times two], CABG [Coronary Artery Bypass Graft-an operation where a surgeon uses a blood vessel from another part of the body to go around/bypass blocked heart arteries so blood can reach the heart more easily], Plavix [blood thinning medication]...MI[myocardial infarction-a heart attack]...CVA[cerebral vascular accident-a stroke]...BIBA [brought in by ambulance] presents s/p [status post, after something happened] fall. Patient reports a mechanical fall out of bed onto the tile floor face first w/ [with] preluding [a sign that something is about to happen] dizziness. He complains of head and neck pain w/ notable right periorbital hematoma [a bruise with bleeding under the skin around the eye] and small laceration [a cut or tear in the skin] to right ear...” During the review of Patient 14’s medical record with the SCA, there was no documented evidence of a Conditions of Admissions (CoA). On December 23, 2025, at 11:52 a.m., an interview was conducted with the DPA. The DPA stated there was no signed CoA form in Patient 14’s medical record. The DPA further stated Patient Access Service (PAS) gives the patient the CoA to sign upon admission. She stated if the patient is unable to sign the form, it should be indicated on the form “unable to sign”, and PAS needs to make another attempt to get the form signed and document how many attempts were made. The DPA stated if family members are available the family member or an authorized representative can sign in lieu of the patient. The DPA stated not having this document signed can lead to “issues with consent, implications for denial of payment from the patient or insurance.” The facility P&P titled “Registration and Code Trauma Registration,” dated January 27, 2022, was reviewed. The policy indicated, “...documents...prior to treatment or admission to the hospital, the patient or legal guardian or responsible party is asked to sign the Conditions of Admission...the admission document should be signed during the full registration process. If this is not possible, the document should be noted “patient unable to sign and why” if an immediate family member is available, he or she will be asked to sign for the patient...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50122 Based on interview and record review the facility failed to implement their policy and procedures (P&P) for seven of 24 sample patients (Patients 1, 3, 5, 13, 14, 17 and 23), when: 1. For Patient 1, there was no clarification from the physician for two pain medication orders with duplicate pain severity levels (defines how intense pain feels, typically using a 0-10 scale grouped into Mild (1-3), Moderate (4-6), and Severe (7-10); 2. For Patients 3, 17, and 23, pain was not assessed/reassessed before and/or after pain medications were administered; 3. For Patients 5 and 13, an allegation of abuse was not reported to outside agencies following an assessment by telepsychiatry (psychiartry, or mental health care provided by video or phone instead of an in-person visit); 4. For Patient 13, a translator was not provided for a patient who was non-English speaking; 5. For Patient 13, patient identification was not corrected prior to admission, which delayed treatment and transfer to psychiatric facilities; 6. For Patient 13, an intravenous line placed in the field (outside of the facility) was not removed after 48 hours; and 7. For Patient 14, a physician order for neurological assessment was not followed. These failures had the potential to jeopardize the health and safety of the patients, cause harm, an increase in pain, a delay in care, potential further abuse, contribute to delayed identification of a change in the patient’s condition, and an increase in hospital stay. Findings: 1. On December 19, 2025, at 9 a.m., a review of Patient 1’s medical record was conducted with the Quality Nurse (QN) 1. A facility document titled, “History and Physical,” dated August 18, 2025, at 6:41 p.m., was reviewed and indicated, Patient 1 was admitted to the facility on August 18, 2025, at 6:23 p.m., for acute cholecystitis (sudden inflammation of the gallbladder requiring prompt medical treatment, usually surgery). A facility document titled, “Order Information,” dated August 19, 2025, at 12:01 p.m., was reviewed and indicated an order for “...morphine [an analgesic and narcotic drug obtained from opium and used medicinally to relieve pain]...Dose...4 [four]...Dose unit...mg [milligram-unit of measurement]...Route of administration...IV [intravenous - the method of delivering fluids, medication, blood, or nutrients directly into a person’s vein through a needle or soft tube (catheter) for rapid absorption into the bloodstream] Push [pushed through IV line with a syringe]...Frequency [how often]...q4h [every four hours]...PRN [as needed] reason...Pain 7-10 (Severe)...” A facility document titled, “Order Information,” dated August 20, 2025, at 3:27 p.m., indicated, “...Hydrocodone-acetaminophen [Norco, a prescription combination medication used to treat moderate to severe pain] 10mg-325mg)...1 Tabs [tablet]...Route...Oral [by mouth]...Frequency...q4H...PRN...yes...PRN Reason...Pain 7-10 (Severe)...” A facility document titled, “Pain Assessment,” dated August 21, 2025, at 10:40 p.m., was reviewed and indicated Patient 1 had a pain level of 8/10 to his abdomen. A facility document titled, “Medication Administration Record [MAR],” dated, August 21, 2025, at 10:45 p.m., was reviewed and indicated a dose of hydrocodone-acetaminophen (Norco 10mg/325mg) was administered. On December 23, 2025, at 11 a.m., an interview was conducted with the Director of Pharmacy (DOP). The DOP stated “...The orders for morphine and Norco should have been clarified with the provider. The original order, one is injection and one is oral should be clarifying which should be taken and when...It should have been clarified because it is giving the nurse the choice of medication...Clarification should be according to the physician order and not leaving it up to the nurse to make the decision...Physician did not clarify when to use IV and PO [oral]...It should have been the physician to write the order appropriately...” On December 23, 2025, at 2 p.m., an interview was conducted with the Director of Quality (DOQ). The DOQ stated, “There should have been an alert for a duplicate order, and the pharmacist should have caught that...” The facility P&P titled, “Physician’s Orders,” revised June 17, 2024, was reviewed. The P&P indicated, “...If there is any difficulty in reading and/or understanding a providers order, the licensed employee shall contact the provider for clarification...” 2a. On September 19, 2025, at 9 a.m., a review of Patient 3’s medical record was conducted with the QN 1. A facility document titled, “History and Physical,” dated December 17, 2025, at 11:58 p.m., was reviewed and indicated Patient 3 was admitted to the facility on December 17, 2025, for pneumonia (a lung infection that inflames the air sacs (alveoli), causing them to fill with fluid or pus). Patient 3 had a medical history of hypothyroidism (a condition where a butterfly-shaped thyroid gland, located in the neck, doesn’t produce enough essential thyroid hormones) and osteoporosis (a bone disease making bones thin, weak, and porous). A facility document titled, “Orders,” dated December 18, 2025, at 7:09 a.m., indicated, an order for “...morphine...2 mg...IV Push...q4H...PRN...Pain 4-6 (moderate)...” A facility document titled, “MAR,” indicated on December 18, 2025, at 7:10 a.m., Patient 3 received an administration of morphine 2 mg in the IV. A facility document titled “Pain Assessment Detail,” dated December 18, 2025, at 7:10 a.m., was reviewed. There was no documented evidence Patient 3’s pain level assessed prior to or after administration of morphine for pain. 2b. On December 22, 2025, at 2:34 p.m., a review of Patient 17’s medical record was conducted with the Senior Clinical Analyst (SCA). The facility document titled “History and Physical,” dated December 13, 2025, at 11:37 p.m., was reviewed. The document indicated “...chief complaint/reason for consultation...pt had Lebray [sic-Libre] 3 [blood sugar monitoring sensor] placed in R [right] upper arm placed [sic] 4 months ago. Pt [patient] c/o [complaining of] swelling and tingling...past medical history significant for DM [diabetes mellites, a disease where the body cannot control blood sugar] type 1, hypertension, pancreatic cancer [cancer of the pancreas, an organ in the abdomen that makes insulin to control blood sugar and produce digestive fluids to help break down food]. The facility document titled, “Orders,” dated December 13, 2025, indicated “...Toradol [pain medication] 10 mg tab Q [every] 6 hours for 1-3 (pain mild)... hydromorphone [pain medication] 1mg Q4hr PRN for pain 7-10 (severe)...” An untitled facility document for Patient 17’s pain assessment and pain reassessment was reviewed. The document indicated Toradol was administered on December 15, 2025, at 9:36 a.m., assessment indicated at 8:52 a.m; 4/10 [four out of 10] pain scale reassessment at 10:36 a.m., indicated 2/10 [2 out of 10] pain scale. There was no documented evidence of medication parameters that reflect 4/10 pain scale. There is no documented evidence of any communication to the provider regarding the medication parameters. On December 15, 2025, at 4:24 p.m., the documented pain assessment was 8/10 [8 out of 10] on the pain scale. On December 15, 2025, 4:24 p.m., Hydromorphone 1 mg was administered. There was no documented evidence of a reassessment noted. On December 23, 2025, at 12:10 p.m., an interview was conducted with the DOQ. The DOQ stated, it was not appropriate to administer the Toradol outside of the provider parameters, the nurse should have called the provider and get permission or verbal order for a medication that covers the parameter and document. The DOQ further stated reassessment for pain should be done within one hour of pain medication administered and this was not done after the Hydromorphone was given. 2c. On September 23, 2025, at 9:20 a.m., a review of Patient 23’s medical record was conducted with the QN 1. A facility document titled, “History and Physical,” dated October 14, 2025, at 1:12 p.m., indicated Patient 23 was admitted to the facility for abdominal pain and distention (visible swelling of the belly) and hypotension (abnormally low blood pressure). Patient 23 had a medical history of breast cancer (a disease where cells in the breast grow uncontrollably, forming tumors that can be benign (non-cancerous) or malignant (cancerous) and spread to other body parts), coronary artery disease (when plaque (fatty deposits) builds up in your heart’s arteries), hypertension (abnormally high blood pressure), heart attack (the flow of blood that brings oxygen to a part of your heart muscle suddenly becomes blocked), and heart stents (a tiny, expandable wire mesh tube placed inside a narrowed or blocked coronary artery to keep it open, restoring blood flow to the heart). A facility document titled, “Order,” dated October 13, 2025, at 9:39 p.m., was reviewed and indicated an order for “...hydrocodone-acetaminophen (Norco 10 mg - 325 mg oral tablet...Dose...1...Dose unit...1 Tabs...Frequency...once...” A facility document titled, “MAR,”, dated October 13, 2025, at 9:46 p.m., was reviewed and indicated a dose of “...hydrocodone-acetaminophen...10 mg...1 Tab...” was administered. A facility document titled, “Pain Assessment Detail,” on October 13, 2025, at 9:45 p.m., indicated a pain level of 8/10 prior to administration of hydrocodone-acetaminophen. There was no documented evidence of a pain assessment after administration of hydrocodone-acetaminophen. On December 23, 2025, at 12 p.m., an interview was conducted with the DOQ. The DOQ stated, “...Pain should be assessed an hour after administration and prior to administration...reassessment of pain is necessary for assessing effectiveness of intervention...Assessment/reassessment is important to know because it shows if the medications were effective adequately with the dose and type of pain meds used...” A review of the facility P&P titled, “Medication Ordering and Administration,” revised December 16, 2022, indicated “...Administered PRN medications must be documented in the medical record along with the indication for administration and patient response...” 3a. On December 19, 2025, a review of Patient 5’s medical record was conducted with the QN 1. A review of the facility document titled, “ED [Emergency Department] Physician Record,” dated December 16, 2025, at 5:31 p.m., authored by Medical Doctor (MD) 9 indicated Patient 5 was brought into the ED by ambulance on a psychiatric hold (5150-allows for an involuntary 72-hour psychiatric hold for individuals deemed a danger to themselves, a danger to others, or gravely disabled due to a mental disorder, typically initiated by law enforcement or mental health professionals during a crisis) for threatening to kill self with a knife after a domestic dispute with spouse and intoxication (a condition that follows the administration of a psychoactive substance and results in disturbances in the level of consciousness, thought process, judgement, or behavior) with wine. Patient 5 had a medical history of HTN, and hyperlipidemia (high cholesterol). A review of the facility document titled, “Consult-Psychiatry,” dated December 16, 2025, at 8:29 a.m., authored by MD 7, indicated Patient 5 had an “...ongoing mental/emotional mistreatment...Patient expresses that home is not emotionally safe and does not want spouse at home...Reports of expressed suicidality appears to be in context of her being intoxicated at that time and relationship discord [unstable relationship] with spouse...Reports emotional abuse by husband but denies physical abuse...” A review of the facility document titled, “ED Physician Record,” dated December 18, 2025, at 3:18 p.m., authored by MD 8, indicated, “...Patients hold expired...Patient discharged subsequently to daughter’s care in stable condition...” There was no documented evidence found in Patient 5’s medical record to show any mandated reporter documentation completed. 3b. On December 19, 2025, at 9:17 a.m., Patient 13’s medical record was reviewed with the Clinical Supervisor (CS). The document titled “History and Physical,” dated September 14, 2025, at 2:53 a.m., was reviewed. The document indicated Patient 13 has “...history of bipolar disorder [a mental health condition that causes usual, significant shifts in mood, energy, and activity level], anxiety [intense or mild feelings of worry, nervousness, or fear], depression [a mental health condition that includes persistent sadness or lost of interest] presents to our hospital today after drug overdose with Sertraline [a prescription medicine that helps treat depression and anxiety], Abilify [ a prescription medicine that helps stabilize mood and thinking], Ibuprofen [an over the counter medicine that helps relieve pain, reduce fever and decrease swelling and inflammation] and patient saying that she felt sad and wanted to go to sleep and took those medications. Patient reportedly took a full bottle of these medications per [spouse]. At bedside.[sic] Her [Spouse] had found the patient in the closet, nonresponsive and called 911...” The document titled “ Progress Note - Physician,” dated September 17, 2025, at 11:08 a.m., was reviewed. The document indicated “...it seems that [name of spouse] and Patient 13 have been arguing on phone. Staff has heard [name of spouse] being quite rude to her, to children. Sitters have seen [name of spouse] head butting of one of his kids. Also heard [name of spouse] being really inappropriate to her. She has [name of spouse] listed in phone as [Name of Spouse] Monster...On deeper level, entire picture just doesn’t feel right. Charge nurse is female....we both tried several ways to talk about abuse, trafficking...and she denies, her explanations however just didn’t feel right and left me with sense of potentially abused woman. Though also a very traditional stay at home mom...despite both professed love for each other. Their relationship seems less than ideal. I am very concerned about what staff have witnessed and we definitely have obligation to call CPS [Child Protective Services]...” On December 19, 2025, at 2:19 p.m., an interview was conducted with the Registered Nurse (RN) 1 . RN 1 stated “...[Spouse] personality was abrupt and confrontational with Patient 13 and the sitters also stated the [Spouse] personality was abrupt and confrontational with Patient 13 and the children...” RN 1 further stated, “...[Name of Spouse] got confrontational about the hold [psychiatric hold] with one of the doctors that was in the room and the doctor had to ask [name of spouse] not to speak for Patient 13...” RN 1 stated that she told the social worker and the charge nurse about the situation. There was no documented evidence that suspected abuse was reported to the appropriate outside agencies. On December 22, 2025, at 3:35 p.m., an interview was conducted with the DOQ. The DOQ stated, “...there is an expectation of a conversation between the telepsych provider and either the attending and/or the ED attending regarding concern for suspected abuse. Any concerns for abuse should be reported per mandated reporter requirements. The telepsych provider is a mandated reporter and should have escalated his concerns to the attending physician and he did not do that...” A review of the P&P titled, “...Screening and evaluation for abuse...should be conducted by all staff, utilizing criteria listed below at admission and on an ongoing basis...Hospital personnel identifying individuals that have met criteria of suspected abuse...should initiate the mandated reporting and hospital referral process...Permits those required to report elder abuse to also report mental abuse...Domestic abuse...psychological distress...suicidal ideation...The mandated reporter with first knowledge of the suspected abuse will carry out both of these reporting mechanisms...” 4. On December 19, 2025, at 9:17 a.m., Patient 13’s medical record was reviewed with the Clinical Supervisor (CS). The document titled “History and Physical,” dated September 14, 2025, at 2:53 a.m., was reviewed. The document indicated Patient 13 had “...history of bipolar disorder, anxiety, depression presents to our hospital today after drug overdose with Sertraline, Abilify, Ibuprofen and patient saying that she felt sad and wanted to go to sleep and took those medications. Patient 13 reportedly took a full bottle of these medications per [spouse]. At bedside. Her [Spouse] had found the patient in the closet, nonresponsive and called 911...” The document titled “Progress Note - Nurse,” dated September 16, 2025, at 8:41 p.m., was reviewed. The document indicated a facility system approved text conversation between RN 1 and MD 7. “...RM (sic, RN) patient is still requesting for an update to be given by the psychiatrist...she is saying she would like to be re-evaluated because she speaks Vietnamese and did not understand the plan...MD...she was able to communicate quite clearly during previous assessment and today’s assessment. I felt like she clearly understood what I was recommending, the issue is that she is not agreeing with it...I don’t see the need for another psychiatric assessment, at least for today...” The document titled “Progress Note - Nurse,” dated, September 16, 2025, at 8:53 p.m., authored by RN was reviewed. The document indicated “...informed social worker that patients psych re-eval [reevaluation] recommends 5250. Hold expires today. Patient disagrees that it was not a fair encounter as she speaks Vietnamese and no translator was used. I let primary team know...” A review of the facility undated document titled “Preferred Mode of Communication for Health Care Discussions,” indicated “...patient’s preferred language...Vietnamese...preferred language interpreter required...yes, for language...” On December 19, 2025, at 10:11 a.m., an interview was conducted with the CS. The CS stated, “...the patient should have had her psych [Psychiatry] evaluation in the language she preferred when requested...” The facility P&P titled “Interpreter: Language Access for Limited English Proficient [LEP]and Hearing-Impaired Patients,” dated January 24, 2024, was reviewed. The policy indicated, “...the hospital shall provide reasonable accommodations as required by law to ensure effective communication between care providers, patients and their surrogate decision makers for those with LEP...to ensure them an equal opportunity to benefit from services...The basis for determining whether your barrier to communication exist is based upon the patient or family statement of need. In assessing whether a barrier exists, [Name of Facility] shall identify the patient’s oral and written communication needs, including the patient preferred language for discussing health care...Any interpretation that requires asking and/or giving of detailed medical information and/or informed consent requires the use of a qualified medical interpreter, available through the contracted language services provider...” 5. On December 19, 2025, at 9:17 a.m., Patient 13’s medical record was reviewed with the CS. The document titled “History and Physical,” dated September 14, 2025, at 2:53 a.m., was reviewed. The document indicated Patient 13 had “...history of bipolar disorder, anxiety, depression presents to our hospital today after drug overdose with Sertraline, Abilify, Ibuprofen and patient saying that she felt sad and wanted to go to sleep and took those medications. Patient reportedly took a full bottle of these medications per [spouse]. At bedside. Her [Spouse] had found the patient in the closet, nonresponsive and called 911...” A review of the document titled, “Application for assessment, evaluation and crisis intervention or placement for evaluation and treatment,” dated September 13, 2025, was reviewed. The document indicated the patient’s name was spelled “Quyen [last name of patient].” A review of a document titled “Valuables/Belongings,” dated September 17, 2025, at 1:25 p.m., indicated the patient spelled her name “Quyen [last name of patient].” A review of a copy of the patient’s Driver’s license indicated the patient’s legally correct name is spelled “Queenie [last name of patient].” A review of the document titled “Progress Note - Care Manage/Social Work,” dated September 15, 2025, at 11:42 a.m., indicated “...[Name of Psychiatric Facility] called and reported difficulty verifying insurance information...[Name of Second Psychiatric Facility] called and said have an available bed however the pt [patient] correct name [sic - needs] to be on 5150 hold before accepting...” There was no documented evidence the name was corrected on the 5150 hold. On December 19, 2025, at 11:36 a.m., an interview was conducted with the Director of Patient Access and Registration (DPA). The DPA stated, “...when patients first come into the Emergency Department [ED] they are checked in by the ED clinical staff. Patient Access Service (PAS) staff does the full registration, we did scan in Patient 13 ID [identification] and the insurance, we have to wait for clinical clearance before updating the name. The DPA stated there is a policy to guide the PAS staff on what to do when an error in patient name is found...” The DPA stated there is no documentation indicating the incorrect name was documented and pending medical clearance and stated it is the expectation to document in the patient’s chart the patient’s name was incorrect and needed to be updated. The DPA stated the PAS staff is responsible for comparing the information the clinical staff initially documented regarding the patient’s information to the ID and insurance provided, and the expectation is if the information does not match the PAS staff should document there is a discrepancy and pending medical clearance. The DPA stated this was not done. On December 19, 2025, at 1:20 p.m., a telephone interview was conducted with the Social Worker (SW). The SW stated “...we don’t write 5150, we do check the spelling. We did note that her name was spelled incorrect on September 15th. If law enforcement writes the hold, we ask them to come back and fix the document...” On December 22, 2025, at 9:10 a.m., an interview was conducted with the DPA. The DPA stated “...we would always default to the legal identification, even though the patient printed and signed their name with the incorrect spelling...” The facility P&P titled “Registration and Code Trauma Registration,” dated January 27, 2022, was reviewed. The P&P indicated “...registration...All potential patients go through the Patient Access Service Department for registration...During full registration, demographic and guarantor information is obtained and entered into the registration system...Pertinent comments relating to the admissions/registration/verification process are entered in the hospital’s computer system...in the comments section...The patient’s registration may be updated when the physician states that no blood or blood products are anticipated for the next 24 hours...the nurse contacts PAS and informs them that registration information can be updated...PAS updates registration with validated information...” 6. On December 19, 2025, at 9:17 a.m., Patient 13’s medical record was reviewed with the CS. The document titled “History and Physical,” dated September 14, 2025, at 2:53 a.m., was reviewed. The document indicated Patient 13 had “...history of bipolar disorder, anxiety, depression presents to our hospital today after drug overdose with Sertraline, Abilify, Ibuprofen and patient saying that she felt sad and wanted to go to sleep and took those medications. Patient 13 reportedly took a full bottle of these medications per [spouse]. At bedside. Her [Spouse] had found the patient in the closet, nonresponsive and called 911...” On December 19, 2025, at 10:44 a.m., the E-Medical Record of the Peripheral IV Flowsheet for Patient 13 was reviewed. The flowsheet indicated Patient 13 was admitted with a Left AC (antecubital, inner bend of elbow) 18 G [Gauge, size of IV) peripheral IV [a small device placed in the vein to give medication] on September 13, 2025, at 1:20 p.m., and was removed on September 16 at 9:20 p.m. The IV was left in place for a total of 80 hours. There is no documented evidence there was difficulty finding a new IV site or another IV was difficult to find or place. On December 18, 2025, at 11:30 a.m., an interview was conducted with RN 2 during a tour of the facility. RN 2 stated that if she received a patient who was admitted with an IV that was placed in the field (outside the facility), she would immediately remove the IV and place a new IV. On December 19, 2025, at 2:24 p.m., an interview was conducted with the DOQ. The DOQ stated that per the policy the IV should have been changed within a 48 hour window, they could have had an issue with the IV site. The person who puts in the outside IV is not governed by our (the facility) procedures so this is why it is policy to remove the IV within 48 hours. She further stated this is risk for infection due to potential suboptimal (not the best or ideal conditions) field conditions. The facility P&P titled “Intravenous Therapy,” dated October 27, 2022, was reviewed. The P&P indicated “...general IV process...all peripherally inserted intravenous catheters initiated in the pre-hospital setting by paramedics will be changed within 48 hours...” 7. On December 22, 2025, at 9 a.m., Patient 14’s medical record was reviewed with the SCA. The document titled “History and Physical,” dated March 24, 2025, at 12:09 p.m., indicated, Patient 14 had a past medical history of “...CAD [Coronary Artery Disease-Arteries that supply blood to the heart become narrowed or blocked], cardiac stent [small mesh tube that a doctor places inside a heart artery to hold it open so blood can flow more easily ot the heart muscle] x 2 [times two], CABG [Coronary Artery Bypass Graft-an operation where a surgeon uses a blood vessel from another part of the body to go around/bypass blocked heart arteries so blood can reach the heart more easily], Plavix [blood thinning medication]...MI[myocardial infarction-a heart attack]...CVA[cerebral vascular accident-a stroke]...BIBA [brought in by ambulance] presents s/p [status post, after something happened] fall. Patient reports a mechanical fall out of bed onto the tile floor face first w/ [with] preluding [a sign that something is about to happen] dizziness. He complains of head and neck pain w/ notable right periorbital hematoma [a bruise with bleeding under the skin around the eye] and small laceration [a cut or tear in the skin] to right ear...” A review of the document titled “Neurological Assessment,” dated March 25, 2025, at 6:27 a.m., indicated that neurological assessments needed to be conducted by the nurse “...frequency [how often]...q4H [every four hours]...next dose Dt [date] tm [time] 10:00...” An interview with the SCA stated that the order indicated the order was modified to begin neurological assessments every four hours starting at 10 a.m. On December 22, 2025, at 10:25 a.m., the neurological assessment flowsheet was reviewed with the SCA. The flowsheet showed the neurological assessment was completed on March 25, 2025, at 10 a.m. per order, then March 25, 2025, at 3:20 p.m., and March 25, 2025, at 7:55 p.m. The time interval between the 10 a.m. and 3:20 p.m., assessments were 5 hours and 20 minutes, and the time intervals between the 3:20 p.m., and 7:55 p.m. assessments were 4 hours and 35 minutes. On December 22, 2025, at 10:28 a.m., an interview was conducted with the SCA. The SCA stated the neurological assessments should have occurred at 2 p.m., per the order but were not done. The SCA further stated that the next assessment should have been at 6 p.m., per the order but there is no assessment at 6 p.m. On December 23, 2025, at 1:30 p.m., an interview was conducted with the DOQ. The DOQ stated, staff were expected to complete assessments per physicians’ orders to monitor and identify changes in condition; failure to complete assessments as ordered could result in a missed change in the patient’s condition. The facility P&P titled “Assessment & Reassessment of Patient,” dated June 17, 2024, was reviewed. The P&P indicated “...purpose To establish guidelines delineating the responsibility of the healthcare team in identifying current and future patient care needs...It incorporates assessment and recognition of normal versus abnormal body Physiology and assessment/reassessment frequency...ongoing assessment/reassessment. Will be completed by Department standard unless otherwise ordered or indicated by policy or patient condition...Upon transfer to another level of care, reassessment must include...system specific assessment of those problems identified...””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure allegations of patient abuse were escalated and reported to the House Supervisor, the Manager/Director of the unit, and/or the administrator on-call, in accordance with the facility’s policy and procedure, for one of 20 sampled patients (Patient 16). This failure had the potential for Patient 16, and other patients to experience abuse and harm. Findings: On September 16, 2025, at 11:30 a.m., an interview was conducted with the Director of the Emergency Department (DED). The DED stated on August 13, 2025, she received an email from the medical director of the fire department (MD 1) highlighting concerns about an incident involving an emergency department technician (EDT 1) when a patient was transferred to the facility’s emergency department (ED). The email described that EDT 1 had allegedly slapped Patient 16 in the face and pressed the patient’s head down onto the mattress. EDT 1 was asked to leave the room, and this incident was reported to hospital staff. However, the DED stated this allegation of abuse was not escalated to the house supervisor as required by the facility’s policy. On September 16, 2025, at 1:40 p.m., a review of Patient 16’s medical record was conducted with the Quality Manager (QM). A facility document titled, “ED [Emergency Department] Physician Record,” dated August 12, 2025, authored by Name of Physician (MD 2), was reviewed. The document indicated, Patient 16, was brought to the ED via ambulance following a tonic clonic seizure (a grand mal seizure, a type of seizure that affects the entire brain and body). When the ambulance arrived, Patient 16 was combative, confused and required Versed (a medication used for sedation and anxiety) in route, but it did not have an effect on Patient 16. In the ED, Patient 16 was cursing and uncooperative. A facility document titled, “Patient Care Report,” dated August 12, 2025, authored by the fire department paramedic was reviewed. The document indicated, “...the PT [patient] became combative again with EMS [Emergency Medical Services] and ER [emergency room] staff. Upon attempting to restrain the PT to leather restraints an ER tech at [Name of Facility] was using excessive use of force to restrain the Pt. The tech was twisting the PT upper extremities in unnatural ways and started [sic] that the [sic] was going to break his elbow. The PT grabbed a hold of the ER tech shirt and the tech open hand hit the PT in the face and pushed his face into the mattress. The tech was firmly told to leave due to his behavior and the PT was successfully restrained to the bed...Patient care was transferred to bedside nurse and verbal complaints of the ER tech’s behavior was shared...” A facility document titled. “Patient Care Report,” dated August 12, 2025, authored by the EMS paramedic was reviewed. The document indicated, “...Patient moved from gurney to bed. Patient was placed in restraints...During restraint application [Name of EDT 1] became aggressive wih [sic] pt [patient] and was asked to leave the room...reported to charge nurse...” A facility document titled, “Progress Note,” dated August 13, 2025, at 1:28 a.m., authored by Name of Registered Nurse (RN) 1, was reviewed. The document indicated, “...Pt BIBA [brought in by ambulance], screaming fighting, hitting/kicking, cursing, and threatening staff. MD 2 at bedside. Violent restraints applied...” On September 17, 2025, at 9:10 a.m., an interview was conducted with RN 1. RN 1 stated on August 12, 2025, Patient 16 arrived in the ED via ambulance, exhibiting combative behavior, cursing, yelling, and threatening staff. RN 1 noted that EDT 1 restrained Patient 16’s right arm in an “awkward” position and heard the EMS paramedic instructing EDT 1 to leave the room due to his “rough” actions. RN 1 also stated that she did not inform the charge nurse/clinical supervisor about the incident. On September 17, 2025, at 9:50 a.m., an interview was conducted with the Charge Nurse/Clinical Supervisor (RN) 2. RN 2 stated she was informed by EDT 1 that the EMS paramedic had asked him to leave Patient 16’s room due to his aggressive behavior. RN 2 further stated that the paramedic reported EDT 1’s behavior as unacceptable and aggressive. RN 2 explained that in such cases, the policy is to immediately send the perpetrator home, notify the house supervisor, director, and law enforcement, but none of these steps were followed. On September 17, 2025, at 3:30 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated on August 13, 2025, she became aware of an incident where EDT 1 was accused of using excessive force while restraining Patient 16. The DQ stated RN 1 and RN 2 should have reported this alleged abuse to the house supervisor, administrator on call, or the Director of the Emergency Department (DED) immediately upon learning about it, but this was not done. The DQ stated the facility’s policy was not followed. A review of the facility Policy and Procedure (P&P) titled, “Escalation and Chain of Command,” dated July 28, 2022, was conducted. The policy indicated, “... Any employee or medical staff member who identifies a problem and is unable to resolve it should utilize Escalation and the Chain of Command until a satisfactory resolution is achieved. Examples include... Unprofessional conduct involving any health care worker... a patient safety or safety event that does not meet established guidelines placing patient(s) or team members at risk... Escalation/Chain of Command ensures...the appropriate people are aware of the problem or concern... The problem or concern advances through the Chain of Command until resolution is attained...the House Supervisor is the on duty administrative representative; any staff member may contact the House Supervisor for assistance. Additionally, there is an Administrator On-Call....The Administrative Chain of Command is as follows...Clinical Supervisor or designated lead of the unit/department...House Supervisor...Unit/department Manager or Director... Administrator on-Call...Chief Nursing Officer or Chief Operating Officer...Chief Executive Officer...Staff who encounter a patient care concern or other safety issue which, in their judgment could be detrimental to the patient, team member, or the facility must initiate the Chain of Command...Implementation of the chain of command requires voice-to-voice communication...Escalation can occur within one or both Chain of Commands (Administrative, Medical staff) for a given situation...” A review of the facility P&P titled, “Workplace Violence,” dated March 22, 2018, was conducted. The policy indicated, “...Reporting suspected Violent Tendencies or Acts of Violent Behavior... a supervisor or an employee who encounters or witnesses a situation or act such as harassment, intimidation or verbal abuse or threat that does not pose an immediate danger to others must immediately report the incident to a direct supervisor, Administration or the HR department...The individual reporting the incident must provide documentation including specifics such as the name of the individual posing the threat (if known), the date and time of the incident, what was said, to whom it was directed and any other information which will assist in ensuring safety and expediting an investigation of the reported incident...” A review of the facility P&P titled, “Abuse and Neglect: Recognition and Reporting,” dated September 15, 2016, was conducted. The policy indicated, “...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation...[Name of Facility] strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, or family members...Definitions...Abuse - intentional maltreatment of an individual, which may cause injury, either physical or psychological. This includes mental abuse physical abuse and sexual abuse period...Mental abuse - includes humiliation, harassment, and threats of punishment or deprivation...Physical abuse - includes hitting, slapping, pinching, or kicking. Also includes controlling behavior through corporal punishment...Healthcare Practitioner / Mandated Reporter: means a physician, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse (RN/LVN [licensed vocational nurse]), dental hygienist, optometrist, marriage and family therapist, clinical social worker, emergency medical technician I [one] or II [two], paramedic or other person; psychological assistant, state or county public employee who treats a minor for venereal disease (sexually transmitted disease) or any other condition; coroner; or a medical examiner or person who performs autopsies...Hospital personnel identifying individuals that have met criteria of suspected abuse neglect or exploitation should initiate the mandated reporting and hospital referral process...Hospital personnel...will immediately notify their manager or a mandated reporter...Reporting procedure...Appropriate law enforcement agency...will be notified via telephone immediately or as soon as practically possible after receiving information regarding the incident...” A review of the facility P&P titled, “Patient’s Rights and Responsibilities,” dated August 25, 2022, was conducted. The policy indicated, “... To establish guidelines to ensure that patients are informed of their rights and responsibilities regarding their care, treatment, and services and to assist patients in exercising their rights. To provide an environment that respects patients’ values, beliefs, and preferences...Patient Rights...You have the right to...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying governmental agencies of neglect or abuse...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48776 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for two of 20 sampled patients (Patients 15, and 16), when: 1. For Patient 15, the facility failed to ensure a leaving against medical advice (AMA) form was completed; and 2. For Patient 16, the facility failed to ensure allegations of patient abuse were escalated and reported to the House Supervisor, the Manager/Director of the unit, and/or the administrator on-call. These failures had the potential to compromise patient safety, leaving patients unaware of the risks and possible consequences of leaving AMA, and increased risk of patient abuse and harm. Findings: 1. On September 16, 2025, at 3:10 p.m., a review of Patient 15’s medical record was conducted with the Quality Manager (QM). A facility document titled, “ED [Emergency Department] Physician Record,” dated August 11, 2025, was reviewed. The document indicated, Patient 15, was brought to the ED via ambulance for complaints of left hip pain, and headache. The document further indicated, Patient 15 had a urinary tract infection (UTI, when bacteria enter the urinary system) with a risk for urinary sepsis (when a UTI spreads into the bloodstream and makes the whole-body sick), and needed to be admitted to the facility for further observation, cardiac monitoring, and antibiotics. A facility document titled, “Discharge Request Task Order,” dated August 11, 2025, was reviewed. The document indicated, “...Order...Requested Start Date/Time...8/11/2025 [August 11, 2025] 22:04 [10:04 p.m.]...Discharge To...Against Medical Advice...” There was no documented evidence an AMA form was completed for Patient 15. On September 17, 2025, at 11 a.m., an interview was conducted with the Quality Director (QD). The QD stated Patient 15’s medical record should have included an AMA form and confirmed that the policy was not followed. A review of the facility Policy and Procedure (P&P) titled, “Leaving Prior to Discharge,” dated January 26, 2023, was conducted. The policy indicated, “...When a patient states they are leaving prior to discharge...the patient will be asked to sign the AMA form...Whenever possible, the AMA form should include the risks or possible consequences as stated by the physician/provider...If the patient refuses to sign the AMA form, the nurse documents on the form that the patient refused to sign...The AMA form is incorporated into the patient’s medical record...” 2. On September 16, 2025, at 11:30 a.m., an interview was conducted with the Director of the Emergency Department (DED). The DED stated on August 13, 2025, she received an email from the medical director of the fire department (MD 1) highlighting concerns about an incident involving an emergency department technician (EDT 1) when a patient was transferred to the facility’s emergency department (ED). The email described that EDT 1 had allegedly slapped Patient 16 in the face and pressed the patient’s head down onto the mattress. EDT 1 was asked to leave the room, and this incident was reported to hospital staff. However, the DED stated this allegation of abuse was not escalated to the house supervisor as required by the facility’s policy. On September 16, 2025, at 1:40 p.m., a review of Patient 16’s medical record was conducted with the Quality Manager (QM). A facility document titled, “ED [Emergency Department] Physician Record,” dated August 12, 2025, authored by Medical Doctor (MD) 2, was reviewed. The document indicated, Patient 16, was brought to the ED via ambulance following a tonic clonic seizure (a grand mal seizure, a type of seizure that affects the entire brain and body). When the ambulance arrived, Patient 16 was combative, confused and required Versed (a medication used for sedation and anxiety) in route, but it did not have an effect on Patient 16. In the ED, Patient 16 was cursing and uncooperative. A facility document titled, “Patient Care Report,” dated August 12, 2025, authored by the fire department paramedic was reviewed. The document indicated, “...the PT [patient] became combative again with EMS [Emergency Medical Services] and ER [emergency room] staff. Upon attempting to restrain the PT to leather restraints an ER tech at [Name of Facility] was using excessive use of force to restrain the Pt. The tech was twisting the PT upper extremities in unnatural ways and started [sic] that the [sic] was going to break his elbow. The PT grabbed a hold of the ER tech shirt and the tech open hand hit the PT in the face and pushed his face into the mattress. The tech was firmly told to leave due to his behavior and the PT was successfully restrained to the bed...Patient care was transferred to bedside nurse and verbal complaints of the ER tech’s behavior was shared...” A facility document titled. “Patient Care Report,” dated August 12, 2025, authored by the EMS paramedic was reviewed. The document indicated, “...Patient moved from gurney to bed. Patient was placed in restraints...During restraint application [Name of EDT 1] became aggressive wih [sic] pt [patient] and was asked to leave the room...reported to charge nurse...” A facility document titled, “Progress Note,” dated August 13, 2025, at 1:28 a.m., authored by Name of Registered Nurse (RN) 1, was reviewed. The document indicated, “...Pt BIBA [brought in by ambulance], screaming fighting, hitting/kicking, cursing, and threatening staff. MD 2 at bedside. Violent restraints applied...” On September 17, 2025, at 9:10 a.m., an interview was conducted with RN 1. RN 1 stated on August 12, 2025, Patient 16 arrived in the ED via ambulance, exhibiting combative behavior, cursing, yelling, and threatening staff. RN 1 noted that EDT 1 restrained Patient 16’s right arm in an “awkward” position and heard the EMS paramedic instructing EDT 1 to leave the room due to his “rough” actions. RN 1 also stated that she did not inform the charge nurse/clinical supervisor about the incident. On September 17, 2025, at 9:50 a.m., an interview was conducted with the Charge Nurse/Clinical Supervisor (RN) 2. RN 2 stated she was informed by EDT 1 that the EMS paramedic had asked him to leave Patient 16’s room due to his aggressive behavior. RN 2 further stated that the paramedic reported EDT 1’s behavior as unacceptable and aggressive. RN 2 explained that in such cases, the policy is to immediately send the perpetrator home, notify the house supervisor, director, and law enforcement, but none of these steps were followed. On September 17, 2025, at 3:30 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated that on August 13, 2025, she became aware of an incident where EDT 1 was accused of using excessive force while restraining Patient 16. The DQ stated that RN 1 and RN 2 should have reported this alleged abuse to the house supervisor, administrator on call, or the Director of the Emergency Department (DED) immediately upon learning about it, but this was not done. The DQ stated that the policy was not followed. A review of the facility P&P titled, “Escalation and Chain of Command,” dated July 28, 2022, was conducted. The policy indicated, “... Any employee or medical staff member who identifies a problem and is unable to resolve it should utilize Escalation and the Chain of Command until a satisfactory resolution is achieved. Examples include... Unprofessional conduct involving any health care worker... a patient safety or safety event that does not meet established guidelines placing patient(s) or team members at risk... Escalation/Chain of Command ensures...the appropriate people are aware of the problem or concern... The problem or concern advances through the Chain of Command until resolution is attained...the House Supervisor is the on duty administrative representative; any staff member may contact the House Supervisor for assistance. Additionally, there is an Administrator On-Call....The Administrative Chain of Command is as follows...Clinical Supervisor or designated lead of the unit/department...House Supervisor...Unit/department Manager or Director... Administrator on-Call...Chief Nursing Officer or Chief Operating Officer...Chief Executive Officer...Staff who encounter a patient care concern or other safety issue which, in their judgment could be detrimental to the patient, team member, or the facility must initiate the Chain of Command...Implementation of the chain of command requires voice-to-voice communication...Escalation can occur within one or both Chain of Commands (Administrative, Medical staff) for a given situation...” A review of the facility P&P titled, “Workplace Violence,” dated March 22, 2018, was conducted. The policy indicated, “...Reporting suspected Violent Tendencies or Acts of Violent Behavior... a supervisor or an employee who encounters or witnesses a situation or act such as harassment, intimidation or verbal abuse or threat that does not pose an immediate danger to others must immediately report the incident to a direct supervisor, Administration or the HR department...The individual reporting the incident must provide documentation including specifics such as the name of the individual posing the threat (if known), the date and time of the incident, what was said, to whom it was directed and any other information which will assist in ensuring safety and expediting an investigation of the reported incident...” A review of the facility P&P titled, “Abuse and Neglect: Recognition and Reporting,” dated September 15, 2016, was conducted. The policy indicated, “...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation...[Name of Facility] strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, or family members...Definitions...Abuse - intentional maltreatment of an individual, which may cause injury, either physical or psychological. This includes mental abuse physical abuse and sexual abuse period...Mental abuse - includes humiliation, harassment, and threats of punishment or deprivation...Physical abuse - includes hitting, slapping, pinching, or kicking. Also includes controlling behavior through corporal punishment...Healthcare Practitioner / Mandated Reporter: means a physician, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse (RN/LVN [licensed vocational nurse]), dental hygienist, optometrist, marriage and family therapist, clinical social worker, emergency medical technician I [one] or II [two], paramedic or other person; psychological assistant, state or county public employee who treats a minor for venereal disease (sexually transmitted disease) or any other condition; coroner; or a medical examiner or person who performs autopsies...Hospital personnel identifying individuals that have met criteria of suspected abuse neglect or exploitation should initiate the mandated reporting and hospital referral process...Hospital personnel...will immediately notify their manager or a mandated reporter...Reporting procedure...Appropriate law enforcement agency...will be notified via telephone immediately or as soon as practically possible after receiving information regarding the incident...” A review of the facility P&P titled, “Patient’s Rights and Responsibilities,” dated August 25, 2022, was conducted. The policy indicated, “...To establish guidelines to ensure that patients are informed of their rights and responsibilities regarding their care, treatment, and services and to assist patients in exercising their rights. To provide an environment that respects patients’ values, beliefs, and preferences...Patient Rights...You have the right to...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying governmental agencies of neglect or abuse...””

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 34933 Based on interview and record review, the facility failed to ensure the Conditions of Admission (COA, a consent form to receive treatment while in the facility) was signed by the Patient Access Services Rep (PASR) for one (Patient 10) of 20 sample patients. This failure had the potential to cause a delay in patent care. Findings: A review of Patient 10’s medical record was conducted on September 18, 2025, at 9:35 a.m., with the Clinical Effectiveness Coordinator (CEC). A review of the facility document titled, “History & Physical,” dated July 21, 2025, indicated, Patient 10 was admitted to the facility with diagnoses of hyperglycemia (high amount of sugar in the blood) and Altered Level of Consciousness (confusion) with a history of Dementia (progressive state of decline in mental abilities). A review of the facility document titled “Conditions of Admission/Registration” dated July 21, 2025, was reviewed. The document indicated, the family member gave verbal consent by phone because Patient 10 was medically unable to sign. The area on the form designated for staff to verify consent was left blank. On September 18, 2025, at 12:40 p.m., an interview was conducted with the Director of Patient Access Services (DPAS). The DPAS stated, the COA consent form is signed by the patient or a family member when the patient is in the emergency department. The DPAS stated the family member gave a verbal consent over the phone with the PASR but the form was not signed. The DPAS further stated, it is the facility’s policy that the COA consent form to be signed by the PASR. A review of the facility Policy & Procedure titled, “Condition of Admission,” dated February 27, 2025, indicated, “...During the telephone delivery, the Registration staff will deliver and explain the COA to the patient’s legal guardian or representative. The Registration staff will annotate on the COA consent form and following: the staff person initiating the contact, the name of the representative contacted by phone ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38479 Based on interview and record review, the facility failed to ensure the patient’s rights were promoted and protected, for one of 25 sample patients (Patient 25), when the suspected perpetuator, Registered Nurse (RN) 1, who allegedly touched Patient 25 inappropriately, was not removed from patient care while the facility investigation was in progress on December 4, 2024. In addition, the allegation of sexual abuse was not reported by the facility to the Department (California Department of Public Health, a state agency) and law enforcement on December 4, 2024 (Refer to A-0145). The cumulative effect of these facility failures had the potential to negatively impact the health of Patient 25 and exposed and compromised patients to possible sexual abuse and had the potential to cause harm to the patients who were being provided care for by RN 1 in the facility.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50122 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for four of 25 sample patients (Patients 4, 7, 8, and 25), when: 1. For Patient 4, pain medication was not administered in accordance with the physician’s order (Refer to A 0398); 2. For Patient 7, the urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) care was not performed in accordance with the facility’s P&P (Refer to A 0398); 3. For Patient 8, medication reconciliation (the process of creating the most accurate current list of a patient’s medications and comparing it to new medications ordered by the physician) was not completed prior to Patient 8’s transfer to another facility. In addition, a stat (to be performed immediately) order was not completed as ordered (Refer A 0398); and 4. For Patient 25, the facility staff who was involved in an allegation of sexual abuse was not removed from patient care while the facility conducted an investigation to determine if the allegation of abuse was substantiated. In addition, the allegation of sexual abuse was not reported to the Department (California Department of Public Health, a state agency) and investigated by the facility (Refer to A 0398). The cumulative effects of these systemic failures had the potential to cause harm and delay of treatments to the patients at the facility.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38479 Based on interview and record review, the facility failed to ensure the patient’s rights were promoted and protected, for one of 25 sample patients (Patient 25), when the suspected perpetuator, Registered Nurse (RN) 1, who allegedly touched Patient 25 inappropriately, was not removed from patient care while the facility investigation was in progress on December 4, 2024. In addition, the allegation of sexual abuse was not reported by the facility to the Department (California Department of Public Health, a state agency) and law enforcement on December 4, 2024. These facility failures had the potential to negatively impact the health of Patient 25 and exposed and compromised patients to possible sexual abuse and had the potential to cause harm to the patients who were being provided care for by RN 1 in the facility. Findings: On June 23, 2025, at 2 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated Patient 25 reported RN 1 inappropriately touching her on December 4, 2024. On June 25, 2025, at 11:12 a.m., a concurrent interview and review of RN 1’s personnel file record were conducted with the DQ. The personnel file of RN 1 indicated separate allegations of inappropriate touching were made involving RN 1 on December 4, 2024, and on May 16, 2025, and RN 1’s employment at the facility was terminated on May 16, 2025. The DQ stated on December 4, 2024, Patient 25 reported to Physician (MD) 2 that sometime in June of 2024, after her surgery at the facility, she woke up from anesthesia (the use of medication to induce a state of temporary loss of sensation or consciousness, allowing medical procedures to be performed without pain) and felt RN 1 had been touching her inappropriately. The DQ stated the allegation of sexual abuse reported by Patient 25 was investigated by the Operating Room Manager (ORM) from December 4, 2024, to December 18, 2024, and was unsubstantiated by the facility for lack of sufficient evidence. On June 25, 2025, at 11:18 a.m., the facility policy and procedure for “Abuse and Neglect: Recognition and Reporting,” was reviewed with the DQ. The DQ was unable to provide documentation provision for patient safety by removing the staff out of patient care while the facility is investigating the allegation of abuse was addressed in the facility’s policy. On June 25, 2025, at 12:06 p.m., the Risk Manager (RM) was interviewed. A document retrieved by the RM from MIDAS (the facility’s online abuse reporting system), dated December 4. 2024, was reviewed with the RM. The document indicated the ORM spoke with Patient 25. The document indicated, “...I [Patient 25] woke up from anesthesia and was being touched inappropriately...my legs were propped up and he was touching my (private part). I then immediately woke up...and called my mom to pick me up...[Name of ORM] asked if she new [sic] the nurse and she said it was [name of RN 1]...” The RM was unable to provide documentation RN 1 was taken off patient care while the investigation about the allegation of abuse involving Patient 25 was in progress on December 4, 2024. On June 25, 2025, at 2:04 p.m., a concurrent review of facility timesheets and interview were conducted with the DQ. The timesheet indicated RN 1 worked at the facility on December 5, 6, 11, 12, and 13, 2024. The DQ stated the investigation ended on December 18, 2024, and RN 1 provided patient care while the allegation of sexual abuse investigation was in progress from December 4, 2024, to December 18, 2024. The DQ stated RN 1 should have been taken off patient care immediately after the facility was notified of the allegation of abuse involving RN 1 to protect the patients at the facility. The DQ stated the facility’s policy titled, “Abuse and Neglect: Recognition and Reporting,” dated January 25, 2024, for reporting the incident to proper authorities was not followed. The DQ stated, “No, it was not reported to the state and law enforcement and it should have been according to the regulations.” The DQ stated the allegation of abuse should have been reported to the authorities for authorities to be able to intervene and advocate for the patient. A facility policy and procedure titled, “Abuse and Neglect: Recognition and Reporting,” dated January 25, 2024, was reviewed. The policy indicated, “ ...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. (name of the facility) strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, or family members...Reporting Procedure...Appropriate law enforcement agency and/or a domestic violence agency...will be notified via telephone immediately or as soon as practically possible after receiving information regarding the incident...A written report must be prepared and sent to [Names of two local law enforcement units] within two days...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 38479 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for four of 25 sample patients (Patients 4, 7, 8, and 25), when: 1. For Patient 4, pain medication was not administered in accordance with the physician’s order; 2. For Patient 7, the urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) care was not performed in accordance with the facility’s P&P; 3. For Patient 8, medication reconciliation (the process of creating the most accurate current list of a patient’s medications and comparing it to new medications ordered by the physician) was not completed prior to Patient 8’s transfer to another facility. In addition, a stat (to be performed immediately) order was not completed as orderd; and 4. For Patient 25, the facility staff who was involved in an allegation of sexual abuse was not removed from patient care while the facility conducted an investigation to determine if the allegation of abuse was substantiated. In addition, the allegation of sexual abuse was not reported to the Department (California Department of Public Health, a state agency) and investigated by the facility. These failures had the potential to jeopardize the health and safety of the patients and may cause harm to the patients. Findings: 1. On June 24, 2025, at 9:45 a.m., a review of Patient 4’s record was conducted with the Clinical Effectiveness Coordinator (CEC). A facility document titled, “History and Physical [H&P],” dated June 19, 2025, at 1:23 p.m., was reviewed. The document indicated Patient 4 was admitted to the facility on June 19, 2025, after a motor vehicle accident with T8 (the eighth bone in the thoracic spine, the back bone of the upper back area) chance fracture (a break in the bone), T6 (the sixth bone in the thoracic spine) vertebral body compression fracture (a type of fracture), multiple rib fractures, right sided pneumothorax (the presence of air in the space between the right lung and the chest wall), left sided hemothorax (the accumulation of blood in the space between the lung and chest wall on the left side of the body), and C6 (the sixth bone of the cervical spine, the backbone of the neck) spinous process fracture (a fracture in the bony projection of the bone). A facility document titled, “Original Order,” dated June 21, 2025, at 1:53 p.m., was reviewed. The document indicated, “...OxyCODONE [a pain medication]...5 mg [milligram, unit of measurement]...1 [one] Tab [Tablet]...Route of administration...Oral [to be taken by mouth]...Frequency...q4H [every four hours]...PRN [as needed] reason...Pain 7-10 (Severe) [pain rating score in a tool used to help individuals describe their pain]...” A facility document titled, “Original Order,” dated June 21, 2025, at 1:53 p.m., was reviewed. The document indicated, “...OxyCODONE...2.5 mg...0.5 Tab...Route of administration...Oral...Frequency...q4H...PRN reason...Pain 4-6 (Moderate)...” A facility document titled, “Pain Assessment,” dated June 23, 2025, at 9:26 a.m., was reviewed. The document indicated Patient 4’s pain rating scale was four out of ten to his lower forearm, which indicated moderate pain. A facility document titled, “MAR [Medication Administration Record] Result Details,” dated June 23, 2025, at 9:27 a.m., was reviewed. The document indicated, “...Oxycodone...5 mg...Route...Oral...” was administered to Patient 4. On June 25, 2025, at 2:30 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated the nurse should have followed the physician’s order and and should have given a lower dose of Oxycodone [92.5 mg] based on the pain level of four out of ten. The DQ stated the higher dose of Oxycodone [5 mg] should not have been administered to Patient 4 on June 23, 2025, at 9:27 a.m. A facility policy and procedure (P&P) titled, “Physician’s Order,” revised June 17, 2024, was reviewed. The policy indicated, “...Providers [sic] orders will be accurately processed and promptly followed...” 2. On June 25, 2025, at 8:30 a.m., a review of Patient 7’s record was conducted with the CEC. A facility document titled, “H&P,” dated August 1, 2024, at 3 p.m., was reviewed. The document indicated that Patient 7 was admitted to the facility on August 1, 2024, for transaminitis (high levels of certain liver enzymes in the blood), hyperglycemia (high blood glucose), leukocytosis (high white blood cell [a component of blood] count in the blood, high level indicating infection), and chest pain. A facility document titled, “Orders,” dated August 2, 2024, at 5:43 a.m., was reviewed. The document indicated an order was placed for “...Urinary Catheter...Indwelling/Continuous...” A facility document titled, “Results Review,” dated August 12, 2024, at 8 p.m.,was reviewed. The document indicated, “...No...” indicating a Chlorhexidine (an antiseptic agent that is used to kill or inhibit the growth of bacteria) bath was not done. During the review of Patient 7’s record, there was no documented evidence Chlorhexidine bath was performed on Patient 7. On June 25, 2025, at 2 p.m., an interview with the DQ was conducted. The DQ stated urinary catheter care should have been done in accordance with the facility’s policy and Chlorhexidine should be used daily for patients with a Foley catheter. The DQ stated, “This was not done.” A review of the facility P&P titled, “Urinary Catheter: Preventing Infections,” revised January 27, 2022, was conducted. The policy indicated, “...perineal/meatal care [the region of the body located between the anus and the external genitalia] will be performed by a healthcare provider utilizing hospital approved cleansing product on a daily...basis...” 3a. On June 25, 2025, at 8:30 a.m., a review of Patient 8’s record was conducted with the CEC. A facility document titled, “H&P,” dated May 10, 2025, at 3:47 p.m., was reviewed. The document indicated Patient 8 was admitted to the facility on May 10, 2025, for jaundice (yellowing of the skin) and hypotension (low blood pressure) and had a medical history of anemia (a condition marked by a deficiency of red blood cells [a component of blood]), and alcoholic hepatitis (a serious liver condition characterized by inflammation of the liver due to excessive alcohol consumption). A facility document titled, “Discharge Summary,” dated May 15, 2025, at 10:51 p.m., was reviewed. The document indicated Patient was being discharged to another facility for a higher level of care due to alcoholic hepatitis with ascites (accumulation of fluid in the abdomen). An undated facility document titled, “Orders,” was reviewed. The document indicated, “...Reconciliation Status...Meds [Medication] History...Admission...Discharge...” The document indicated a blue exclamation mark next to “Discharge.”. On June 25, 2025, at 2:20 p.m., an interview was conducted with the CEC. The CEC stated the blue exclamation symbol on the document titled, “orders,” meant the medication reconciliation was not completed. On June 25, 2025, at 2:30 p.m., an interview was conducted with the DQ. The DQ stated the medication reconciliation should have been done on admission, discharge, or transfer of a patient. A facility P&P titled, “Medication Reconciliation Across the Continuum of Care,” revised September 24, 2020, was reviewed. The P&P indicated, “...It is the policy to reconcile patient’s medications at the time of admission...at discharge or transfer to another facility...It is the physician’s responsibility to review the patient’s list, reconcile the patient’s current list of medication to the medications being ordered, and to review and sign the patient’s list at the time of admission...discharge to transfer from the hospital...The Discharging unit provides the discharge medication Reconciliation information...Patient is not to be discharged from the hospital prior to completion of the medication reconciliation process...the physician will be contacted to complete the reconciliation...If the physician...does not complete the Discharge Medication Reconciliation information, the Chain of Command will be utilized...” b. On June 25, 2025, at 8:30 a.m., a review of Patient 8’s record was conducted with the CEC. A facility document titled, “Orders,” dated May 14, 2025, at 1:35 p.m., authored by MD 1, was reviewed. The document indicated, “...norepinephrine [a medication to treat low blood pressure] 8 [eight] mg [milligram, unit of measurement] 4 mcg/min + Premix NS [solution of 0.9% sodium chloride (salt) and water which is administered through a vein (IV, intravenous)] 250 mL [milliliter, unit of measurement]...Order Date: 5/14/2025 [May 14, 2025] 13:35 [1:35 p.m.]...Priority STAT...Action Type: Modify...5/14/25 13:39...Action Personnel: [name of Pharmacist (PHRM) 1...Action Type: Modify...5/14/2025 15:02 [3:02 p.m.]...Action Personnel: [name of PHRM 1]...”...Nurse Review [documentation RN 4 reviewed the oder modified by PHRM 1 on 5/14/25, at 3:02 p.m.]...Electronically Signed, [name of RN 4]...5/14/2025 5:20 [3:20 p.m.,]...” A facility document titled, “Encounter Location History,” dated May 14, 2025, at 1:55 p.m., was reviewed. The document indicated Patient 8 was moved to the intensive care unit (ICU, a specialized area dedicated to providing critical care for patients with life-threatening illnesses) on May 14, 2025, at 1:55 p.m. A facility document titled, “Progress Note-Nurse,” dated May 14, 2025, at 3:08 p.m., authored by RN 3, was reviewed. The document indicated, “...spoke with [Name of physician] per pharmacy request regarding Levophed [brand name for norepinephrine] order in NS vs [versus] D5 [dextrose in water IV solution]. [Name of physician] confirmed Levo [Levophed] to be mixed with NS. Awaiting med [medication] from pharmacy...” A facility document titled, “Medication Administration Record,” dated May 14, 2025, at 3:22 p.m., was reviewed. The document indicated, “...Administration Date/Time...5/14/2025 15:22 [3:22 p.m.] PDT...Medication Name...norepinephrine 8 mg [4 mcg/min] + Premix NS 250 mL...Admin details...Begin Bag...250 mL...7.5 mL/hr...Right Foot...Perform...[Name of RN 4] [one hour and 52 minutes from the time the medication was ordered as stat at 1:35 p.m.]...” On June 25, 2025, at 2 p.m., an interview with PHRM 1 was conducted. PHRM 1 stated the physician placed the order for norepinephrine when the patient was on the Medical Surgical [a hospital unit where patients who require both medical and surgical care are treated]. PHRM 1 stated the pharmacist had to verify the order with the physician because normally the medication is ordered with a different solution. PHRM 1 stated the pharmacist should prepare the medication right away but because the patient was not in ICU at the time of the order, the pharmacist had to wait for the nurse to call the pharmacy when the nurse needs the medication. On June 25, 2025, at 2:15 p.m., an interview with the Pharmacy Manager (PM) was conducted. The PM stated the pharmacy’s process is to hold the medication in the pharmacy until the patient is in a critical care area or an area where the medication can be given. The PM stated Levophed is given in the critical care, ICU, PACU (Post-Anesthesia Care Unit, unit for patients who had undergone surgery) or in a code [code blue, a hospital code for a medical emergency when a patient’s life is in immediate danger] situation. On June 25, 2025, at 2:30 p.m., an interview with the DQ was conducted. The DQ stated the pharmacist should have escalated the issue with the norepinephrine order for Patient 8 to the nurse on the floor where the patient was housed and should have advised the nurse that the pharmacy could not supply the medication until the patient is on a floor where the medication could be dispensed and administered. The DQ stated, “...the nurse in the ICU should have called the pharmacy to obtain the medication in a timely manner...” A facility P&P titled, “Medication Ordering and Administration,” revised December 16, 2022, was reviewed. The P&P indicated, “...Time critical medications...medications where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in sub-optimal therapy [treatment that is less than ideal or not achieving the best possible results] or pharmacological effect [a specific change in the body’s function resulting from the medication]...Order for medications that are emergent and will be executed, including administration to the patient, within 20 minutes from the time the order is written...” A facility P&P titled, “Medication Order Processing,” revised September 15, 2016, was reviewed. The P&P indicated, “...Stat and “Now” orders...Stat orders will be filled by pharmacy and delivered to the nursing floor in time for nursing to administer within 20 minutes from the time the order was written...” A facility P&P titled, “Physician’s Order,” revised June 17, 2024, was reviewed. The P&P indicated, “...Providers orders will be accurately processed and promptly followed...” 4. On June 23, 2025, at 2 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated Patient 25 reported RN 1 inappropriately touching her on December 4, 2024. On June 25, 2025, at 11:12 a.m., a concurrent interview and review of RN 1’s personnel file record were conducted with the DQ. The personnel file of RN 1 indicated separate allegations of inappropriate touching were made involving RN 1 on December 4, 2024, and on May 16, 2025, and RN 1’s employment at the facility was terminated on May 16, 2025. The DQ stated on December 4, 2024, Patient 25 reported to Physician (MD) 2 that sometime in June of 2024, after her surgery at the facility, she woke up from anesthesia (the use of medication to induce a state of temporary loss of sensation or consciousness, allowing medical procedures to be performed without pain) and felt RN 1 had been touching her inappropriately. The DQ stated the allegation of sexual abuse reported by Patient 25 was investigated by the Operating Room Manager (ORM) from December 4, 2024, to December 18, 2024, and was unsubstantiated by the facility for lack of sufficient evidence. On June 25, 2025, at 11:18 a.m., the facility policy and procedure for “Abuse and Neglect: Recognition and Reporting,” was reviewed with the DQ. The DQ was unable to provide documentation provision for patient safety by removing the staff out of patient care while the facility is investigating the allegation of abuse was addressed in the facility’s policy. On June 25, 2025, at 12:06 p.m., the Risk Manager (RM) was interviewed. A document retrieved by the RM from MIDAS (the facility’s online abuse reporting system), dated December 4. 2024, was reviewed with the RM. The document indicated the ORM spoke with Patient 25. The document indicated, “...I [Patient 25] woke up from anesthesia and was being touched inappropriately...my legs were propped up and he was touching my (private part). I then immediately woke up...and called my mom to pick me up...[Name of ORM] asked if she new [sic] the nurse and she said it was [name of RN 1]...” The RM was unable to provide documentation RN 1 was taken off patient care while the investigation about the allegation of abuse involving Patient 25 was in progress on December 4, 2024. On June 25, 2025, at 2:04 p.m., a concurrent review of facility timesheets and interview were conducted with the DQ. The timesheet indicated RN 1 worked at the facility on December 5, 6, 11, 12, and 13, 2024. The DQ stated the investigation ended on December 18, 2024, and RN 1 provided patient care while the allegation of sexual abuse investigation was in progress from December 4, 2024, to December 18, 2024. The DQ stated RN 1 should have been taken off patient care immediately after the facility was notified of the allegation of abuse involving RN 1 to protect the patients at the facility. The DQ stated the facility’s policy titled, “Abuse and Neglect: Recognition and Reporting,” dated January 25, 2024, for reporting the incident to proper authorities was not followed. The DQ stated, “No, it was not reported to the state and law enforcement and it should have been according to the regulations.” The DQ stated the allegation of abuse should have been reported to the authorities for authorities to be able to intervene and advocate for the patient. A facility policy and procedure titled, “Abuse and Neglect: Recognition and Reporting,” dated January 25, 2024, was reviewed. The policy indicated, “ ...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. (name of the facility) strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, or family members...Reporting Procedure...Appropriate law enforcement agency and/or a domestic violence agency...will be notified via telephone immediately or as soon as practically possible after receiving information regarding the incident...A written report must be prepared and sent to [Names of two local law enforcement units] within two days...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to implement their policy and procedure (P&P) for five patients (Patient 15, 16, 24, 29, and 30) when: 1. For Patient 15, daily weights were not taken per physician order and weight loss of 14.99 pounds was not reported to the physician; 2. For Patients 16, 24, and 30, pain levels were not assessed before and after administration of pain medications; 3. For Patient 29, a skin assessment and Braden scale (a tool used in healthcare to assess a patient’s risk of developing pressure ulcers) was not completed on admission. These failures had the potential to jeopardize the health and safety of the patients. Findings: 1. On April 10, 2025, at 8:30 a.m., a review of Patient 15’s medical record was conducted with the Risk Manager (RM) and the Director of Quality (DOQ). On April 10, 2025, at 9 a.m., a review of the facility document titled, “History and Physical [H&P],” dated January 9, 2025, at 2:14 p.m., indicated, “...Inpatient, January 9, 2025 - February 19, 2025...COPD [Chronic obstructive pulmonary disease, a chronic lung disease], chronic hypotension [low blood pressure], malnutrition [a condition caused by an imbalance, deficiency, or excess of nutrients in the body, which can have an adverse effect on the tissue, body form, and function], right hip replacement with prolonged stay...” On April 10, 2025, at 9:10 a.m., a review of the facility document titled, “Order information for Weight,” dated January 8, 2025, at 10:42 p.m., indicated, “...Routine...q24H [every 24 hours]...Special instructions...Daily Weight...” On April 10, 2025, at 9:17 a.m., a review of the facility document titled, “Nutrition Assessment/Plan - Text,” dated January 11, 2025, at 10:56 a.m., indicated, “...Adult Nutrition Reason for Assessment: Consult...low BMI [body mass index, measures body fat based on your height and weight]...Tube Feeding...NPO [nothing by mouth] order...Weight Change, Unintentional...Yes...-4 kilograms [a unit of mass] x 2 months (since Nov [November 2024] ‘24) = -8%...Nutrition Status Compromised: Yes, S/S [signs and symptoms] of Severe Malnutrition...Last documented Height/Weight/BMI....Height/Length Dosing...167.64 cm [centimeters, unit of measurement] January 9, 2025...1:33 p.m...Weight Dosing...45.6 kg [kilograms] January 8, 2025...3:44 p.m...BMI Measured...16.23 kg/m2 [represent two different physical quantities...moment of inertia and surface density]...Monitor/Evaluation...Dietitian follow up/monitor, Monitor weight...High Nutritional Risk...” On April 10, 2025, at 9:17 a.m., a review of the facility document titled, “Vital Sign flow sheet,” was reviewed for the following dates: -January 8, 2025, at 3:44 p.m., 45.6 kilograms - 100.53 pounds on admission; -January 11, 2025, at 6:20 a.m., 43.4 kilograms - 95.68 pounds - a loss of 4.86 pounds; -January 18, 2025, at 6:52 a.m., 40.4 kilograms - 89.07 pounds - a loss of 11.06 pounds; -January 22, 2025, at 6:19 a.m., 41.4 kilograms - 91.27 pounds - a loss of 9.26 pounds; -January 25, 2025, at 5:13 a.m., 42 kilograms - 92.59 pounds - a loss of 7.94 pounds; and -January 26, 2025, at 4:55 a.m., 38.54 kilograms - 85.54 pounds - a loss of 14.99 pounds - this was the last documented weight. There was no documented evidence weights were taken on the following dates: -January 9, 2025, and January 10, 2025 (two days); -January 12, 2025, through January 17, 2025 (six days); -January 19, 2025, through January 21, 2025 (three days); -January 23, 2025, and January 24, 2025 (two days); and -January 27, 2025, through February 19, 2025 (24 days). During the hospitalization, Patient 15 was not weighed per physician’s order on 37 days. There was no documented evidence the physician was notified by staff of Patient 15’s weight loss during her hospitalization. On April 10, 2025, at 9:50 a.m., a concurrent interview and record review were conducted with the RM. The RM stated the nurses did not follow the daily weight order; the last documented weight was on January 26, 2025. The RM further stated the policy was not followed. She stated there was no documentation in the EMR that the physician was notified by the nurses that Patient 15 had a significant weight loss. On April 10, 2025, at 12:52 p.m., a concurrent interview and record review were conducted with the Clinical Nutrition Manager (CNM). The CNM stated it does not look like the weight loss was reported to the physician. A review of the facility P&P titled, “Physician’s Orders,” dated June 17, 2024, indicated, “...Licensed personnel may carry out an order for which there is no established standard, or documented competency in which case the employee will timely notify the provider...Provider orders will be accurately processed and promptly followed...” A review of facility P&P titled, “Nutrition Assessment: Standard Of Care,” dated March 23, 2023, indicated, “...Nutrition Reassessment...A reassessment provides further recommendations and nutritional interventions as needed based on each individual plan of care...Change in weight status...HIGH NUTRITIONAL RISK...Attachment A...feeding modality...tube feeding...Parenteral Nutrition...Weight Status...BMI...18.5 or less [adult 64 yrs (years) and younger]...Difficult Swallowing...Malnutrition...Pressure injury/wounds...Stage 2 or greater...” A review of facility P&P titled, “WWeight [sic] Obtaining Inpatient - Adult and Pediatric,” dated April 28, 2022, indicated, “...To provide clear guidelines to clinical staff on when it is appropriate and necessary to obtain an actual patient weight to ensure optimal clinical patient information to guide patient care, nutrition and medication dosing...It is recommended that patients with the following conditions be considered for frequent or daily weights...Conditions where fluid retention and fluid shift are a concern...Nutritionally compromised patients, including those with tube feedings, high protein needs...Patient experiencing sudden weight loss, or gain in a short period of time...Patients npo for 24 hours or longer...Intensive Care patients should be weighed daily...” 2a. On April 9, 2025, at 10 a.m., a review of Patient 16’s record was conducted with the Clinical Systems Analyst (CSA) and the Senior Clinical Effectiveness Coordinator (SCEC). On April 9, 2025, at 10:05 a.m., a review of the facility document titled, “ED [Emergency Department] Physician Record,” dated March 29, 2025, at 11 p.m., indicated Patient 16 was admitted to the ED for suicidal ideation’s. The document indicated Patient 16 had a medical history of Bipolar disorder (a mental health condition that causes extreme mood swings), Congestive Heart Failure (a condition where the heart cannot pump enough blood to meet the body’s needs, leading to fluid buildup in the lungs and other tissues), Cerebral Vascular Accident (CVA - a medical condition where blood flow to the brain is interrupted) and Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, often causing individuals to experience hallucinations, delusions, and disorganized thinking). On April 9, 2025, at 10:10 a.m., a review of the facility document titled, “Orders,” dated April 8, 2025, at 8:14 a.m., indicated an order for “...Acetaminophen...1000 mg [milligrams - unit of measurement]...2...Tabs (tablets)...Oral [by mouth]...Once...” On April 9, 2025, at 10:15 a.m., a review of the facility document titled, “MAR [Medication Administration Record] Summary,” dated April 8, 2025, at 8:34 a.m., indicated, Patient 16 received a dose of “...Acetaminophen...1,000 mg...2 Tabs...Oral...Once...” On April 9, 2025, at 10:17 a.m., a review of the facility document titled, “Nursing note,” dated April 8, 2025, at 8 a.m., indicated, “...pt [patient] c/o [complained of] allk [sic-all] over body aches. Dr. [doctor - name of physician] notified and orders rec’d [received]. pt [patient] calm and cooperative with staff...” There was no documented evidence of a pain level prior to or after pain medication was administered to Patient 16. On April 9, 2025, at 10:30 a.m., an interview was conducted with the CSA and SCEC. They stated pain should have been assessed prior to and after pain medication was administered to check for a baseline pain level and after to check if treatment was effective. On April 10, 2025, at 1:30 p.m., an interview with the DOQ was conducted. The DOQ stated, an initial pain level should be assessed prior to receiving pain medication and within one hour after pain medication is administered. 2b. On April 9, 2025, at 10:50 a.m., a review of Patient 24’s record was conducted with the CSA and the SCEC. On April 9, 2025, at 11 a.m., a review of facility document titled, “H&P,” dated April 5, 2025, at 10:51 p.m., indicated Patient 24 had a history of Systemic Lupus Erythematosus (a chronic inflammatory, autoimmune disease that can affect many parts of the body), End-stage Renal disease (a severe condition where the kidneys have lost their ability to effectively filter waste and excess fluid from the blood), Hypertension (high blood pressure), and Depression. On April 9, 2025, at 11:05 a.m., a review of the facility document titled, “Order,” dated April 5, 2025, at 10:13 p.m., indicated, an order for “...Hydromorphone (Dilaudid)...1 mg, 1 mL [milliliter- unit of measurement]...Injection...IV [intravenous] Push...q4H Interval...PRN...pain 4-6 (Moderate)...” On April 9, 2025, at 11:10 a.m., a review of the facility document titled, “MAR,” dated April 6, 2025, at 8:40 a.m., indicated “...Site...Left Arm...Hydromorphone 0.5 mg 0.5 mL...Route...IV Push...Given on...April 6, 2025, at 8:40 a.m...Reason for Medication...Pain 4-6 Moderate...” On April 9, 2025, at 11:15 a.m., a review of the facility document titled, “Vital Signs Flowsheet,” dated April 6, 2025, at 8:40 a.m., indicated no initial assessment of pain level prior to pain medication administration. The document further indicated on April 6, 2025, at 8:55 a.m., a numeric pain scale rating of 3 out of 10 after pain medication administration. On April 9, 2025, at 11:30 a.m., an interview was conducted with the CSA and SCEC. They stated pain should have been assessed prior to and after pain medication was given to check for a baseline pain level and after to check if treatment was effective. On April 10, 2025, at 1:30 p.m., an interview with the DOQ was conducted. The DOQ stated, an initial pain level should be assessed prior to receiving pain medication and within one hour after pain medication is administered. 2c. On April 9, 2025, at 11:50 a.m., a review of Patient 30’s record was conducted with the CSA and the SCEC. On April 9, 2025, at 12:30 p.m., a review of the facility document titled, “H&P,” dated March 19, 2025, at 11:11 p.m., indicated Patient 30 had a history of Diabetes (a metabolic disorder characterized by persistently high blood sugar levels) and Hypertension. On April 9, 2025, at 12:35 p.m., a review of the facility document titled, “Order,” dated March 31, 2025, at 10:29 p.m., indicated an order for “...hydrocodone-acetaminophen (Norco 10mg-325 mg oral tablet)...1 Tab...route of administration...PEG-Tube [tube in the stomach]...Frequency...q6H [every 6 hours]...PRN...Yes...PRN Reason...Pain 7-10 (Severe)...” On April 9, 2025, at 12:38 p.m., a review of the facility document titled, “MAR,” dated April 6, 2025, at 8:49 p.m., indicated, “...hydrocodone-acetaminophen (Norco 10 mg...1 Tabs, Tab, Peg-Tube, q6H PRN Pain 7-10 (Severe)...” was administered to Patient 30. On April 9, 2025, at 12:40 p.m., a review of the facility document titled, “Vital Sign Flowsheet,” dated April 6, 2025, at 8:48 p.m., indicated, “...Pain assessment tool...Faces...FACES Pain Scale Score...6...Pain Assessment Detail...Location...Foot...Laterality...Bilateral...” There was no documented evidence of pain being reassessed after pain medication was administered to Patient 30. On April 9, 2025, at 12:45 p.m., an interview was conducted with the CSA and SCEC. They stated pain should have been assessed prior to and after pain medication was given to check for a baseline pain level and after to check if treatment was effective. On April 10, 2025, at 1:30 p.m., an interview with the DOQ was conducted. The DOQ stated, an initial pain level should be assessed prior to receiving pain medication and within one hour after pain medication is administered. A review of the facility P&P titled, “Medication Ordering and Administration,” dated December 16, 2022, indicated, “...Administered PRN [as needed] medications must be documented in the medical record along with the indication for administration and patient response. Assessment of patient response to the medication must occur within one hour following the administration...” A review of the facility P&P titled, “Pain Management,” dated August 26, 2021, indicated, “...[Name of facility] reassesses and responds to the patient’s pain...Evaluates and documents responses to pain interventions...Progresses toward pain management goals including functional ability...Evaluates any side effects of treatment...Evaluates risk factors for adverse events cause by the treatment...” 3. On April 9, 2025, a review of Patient 29’s record was conducted with the CSA and the SCEC. On April 9, 2025, at 1 p.m., a review of the facility document titled, “H&P,” dated March 7, 2025, at 6:54 p.m., indicated, Patient 29 had a history of Chronic Kidney Disease (a condition where the kidneys are damaged and can’t filter blood properly). Patient 29 was admitted on March 7, 2025, at 10:37 a.m., to the Medical/Surgical/Telemetry Unit (a specialized nursing area where nurses provide care to patients requiring continuous cardiac monitoring) for Leukocytosis (elevated white blood cell count). On April 9, 2025, at 1:15 p.m., a review of the facility document titled, “Integumentary [skin system] Flowsheet,” dated March 7, 2025, indicated, no documentation of a skin assessment or Braden scale on admission. On April 9, 2025, at 1:20 p.m., an interview with the Director of Emergency Department (DED) was conducted. The DED indicated, when a patient is admitted and stays in the emergency department, the nurse caring for the patient should be doing a Braden scale and skin assessment. The DED indicated, “I do not see a Braden scale and skin assessment for this patient[Patient 29]...It should have been done per policy...” A review of the facility P&P titled, “Pressure Injuries: Assessment, Documentation and Treatment Guidelines,” dated September 26, 2024, indicated, “...Skin assessment and Braden scale documented on admission and daily...” A review of the facility P&P titled, “Assessment/Reassessment of Patient,” dated June 17, 2024, indicated, “...A Head-to-Toe Assessment is completed and documented on all inpatients upon admission (Body Systems Assessment...Braden Scale...)...within eight (8) hours of admission...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 38479 Based on observation, interview, and record review, the facility failed to ensure standards of nursing practice were followed for four (4) of 30 sampled patients (Patient 2, 3, 13, and 15) when: 1. For Patient 2, Registered Nurse (RN) 2 failed to provide instruction and education for Patient 2’s visitors about infection control and droplet transmission precaution (isolation precaution for patients known or suspected to be infected with micro-organisms transmitted by droplets greater than or equal to five micrometers...in size, that can be generated by the patient during coughing, sneezing, talking, or the performance of cough inducing procedures) for two visitors observed sitting at Patient 2’s bedside without wearing a masks for protection. 2. For Patient 13, RN 3 failed to ensure a STAT order (immediately, should be done without delay) for a MRI (Magnetic Resonance Imaging, a type of diagnostic test that can create detailed images of nearly every structure and organ inside the body) was carried out immediately as ordered for Patient 13. 3. For Patient’s 3 and 15, RN failed to address Patient 3 and 15’s skin breakdown identified on admission, failed to follow through on Patient 3’s wound care consult, and did not document a wound photo weekly, and prior to discharge home per facility policy. These failures had the potential to expose and spread infection to other staff, patients, and visitors, resulted in an 8-hour delay in the identification of progression of stroke (a condition when blood flow to the brain is interrupted, leading to brain cell damage or death), and potential for delay in implementing wound care treatments necessary to prevent infection, tissue growth and healing. Findings: On February 10, 2025, at 8:25 a.m., an unannounced visit was conducted for a complaint validation survey. 1. A tour of the Intensive Care Unit (ICU), was conducted on February 10, 2025, at 9:14 a.m., with the Risk Manager (RM), Director of Women’s Services (DWS), and Clinical Supervisor/Charge Nurse (CS/CN). During the tour RN 2 was observed inside Patient 2’s room, a droplet precaution room, with two visitors sitting bedside without protective masks on. On February 10, 2025, at 9:18 a.m., a concurrent interview was conducted with the CS/CN. The CS/CN stated Patient 2 was positive for Influenza B (type of virus causing Influenza “FLU”, a contagious respiratory illness) and was on isolation precautions. The CS/CN further stated, visitors are supposed to wear masks for droplet precaution to protect themselves and the staff, and to prevent flu transmission (spread of infection). On February 12, 2025, at 9:26 a.m., Patient 2’s medical record was reviewed with the Senior Clinical System Analyst (SCSA). Patient 2’s record indicated Patient 2 was admitted to the facility on February 8, 2025, for Diabetic Ketoacidosis (DKA, a serious complication of diabetes and can be life-threatening) and Influenza. During a concurrent interview with the SCSA, the SCSA stated, per the facility policy, family should be provided with education regarding use of PPE so they are not spreading potential infection to themselves or others. A review of the facility policy titled, “Transmission-based Precaution,” dated April 14, 2023, indicated, “PURPOSE: To provide guideline to prevent the transmission of infections to patients; reduce patient and interdisciplinary health care staff risk of cross transmission of exogenous organisms by providing an appropriate environment, patient placement, management and care of patients with a known or suspected infection or colonization of an infectious agent...Nursing Responsibility...Provide the patient and family members with information on the type of precautions and why the patient was placed in these precautions...ensure all precautions are followed and appropriate PPE is worn...” 2. On February 11, 2025, Patient 13’s medical record was reviewed with the Risk Manager (RM). The “ED Physician Record” indicated, “...presents with altered speech... HTN [hypertension, elevated blood pressure], DM [Diabetes Mellitus, a disorder in which the body does not produce enough or respond normally to insulin {a hormone that regulates blood sugar level}, causing blood sugar levels to be abnormally high]...EMS [Emergency Medical Services] reports pt [patient] was on the phone with her daughter when she had an episode of slurred speech that lasted 3-5 minutes...By the time they arrived the patient symptoms had completely resolved and she was negative on the stroke scale [NIH-National Institutes of Health, helps health care providers assess the severity of stroke]...Reexamination/Reevaluation. Time: 12/15/2024 [December 15, 2024]21:22:00 [9:22 p.m.]. Notes...She was made a code stroke, however, NIHSS [stroke scale] = 0 at this time, so code stroke was cancelled...Patient family arrived and were concerned about her speech. I went back to the bedside to evaluate the patient...her speech remains clear with no facial asymmetry, but due to family concern I did have a stroke code CT [Computed Tomography, non invasive medical examination that uses specialized X-ray equipment to produce cross-sectional images of the body] only called in order to expedite the imaging...High-grade stenosis of the carotid arteries, but no LVO [large vessel obstruction] noted...CT head Noncon [non-contrast] is unremarkable...Given the carotid artery stenosis will admit for further evaluation/management...Impression and Plan...TIA [transient ischemic attack, temporary interruption of blood flow to the brain, causing stroke-like symptoms that typically resolve within 24 hours]. 2. Carotid artery stenosis. Plan. Condition: Stable. Disposition: Patient care transitioned to...NP [Nurse Practitioner]...” Patient 13’s ED Encounter “Event Information”, Timeline indicated: * Arrive, December 15, 2024, 8:28 p.m.; * Triage, December 15, 2024, 8:28 p.m.; * DR (doctor) Exam, December 15, 2024, 8:30 p.m.; and * MSE (Medical Screening Examination, the point at which it can be determined whether the individual has an EMC (Emergency Medical Condition) or not, 8:36 p.m. The facility document titled, “Nursing Note-Text”, dated December 15, 2024, at 9:13 p.m., authored by RN 3 was reviewed and indicated, “...Patient [Patient 13] placed in ER 14 [Emergency Room] for stroke like symptom...[Name of Doctor] cancelled code stroke as exam did not warrant response. [Patient 13’s family]...patient has facial droop on the left side. I assessed the patient who is found to be confused, alert and oriented to person and place only. I did not see the facial droop reported. Informed [Name of Doctor] of the family’s concern...” The facility document titled, “Nursing Note-Text”, dated December 15, 2024, at 11:25 p.m., authored by RN 3, was reviewed and indicated “...patient (sic) is in no acute distress...Neuro check revealed patient is no longer speaking when asked orientation questions. She is not alert but not oriented to time, place, situation, and person...Informed provider via tiger text [communication app]...” On February 11, 2025, at 10:33 a.m., a concurrent record review and interview was conducted with the Stroke Program Manager (SPM) regarding RN 3’s action/inaction of an MRI (magnetic resonance imaging-a medical examination performed using magnetic resonance imaging) STAT (immediately) order placed by the provider on December 16, 2024, at 00:07 a.m. The SPM stated the provider ordered the MRI STAT and the MRI result was completed on December 16, 2024, at 8:34 a.m., 8 hours after the order was placed. Reviewed with SPM MRI brain result that indicated, acute infarction anterior R-MCA (Right-Middle Carotid Artery, an artery in the brain) infarct and infarct r-occipital lobe (back portion of the brain).The SPM stated somebody should have called the on-call tech in. The SPM stated, she believed there should be an urgency in doing the MRI. “I am not sure who is responsible for calling the person on-call”. The SPM stated, they should have done the MRI Stat as ordered because of worsening of symptoms. They should look for any changes. Patient 13 had a known stenosis of the Carotid Artery, they should be looking for a possible occlusion that may necessitate an immediate intervention. On February 11, 2025, at 10:56 a.m., a concurrent interview and record review was conducted with the Director of Radiology (DOR). The DOR stated physician’s order automatically print out in the Radiology printer but after 11:30 p.m., staff are only on-call. Staff are off the property and only the XRAY Tech are in-house. The DOR stated they usually had to wait for the MRI screening to be completed by the nursing staff and it is available in Powerchart for nurses access. The DOR stated they do not need to remind the nurses. They can see it under their “to do/task list”. If MRI screening is completed, XRAY Tech can view it and if there is no contra-indication, they will call the on-call MRI tech who are expected to respond within 30-45 minutes. “Policy and Procedure” for “Scope of Service” was reviewed with DOR that indicated, “Inpatient STAT orders have a response time of 60 minutes”. The DOR stated, for this stroke patient (Patient 13), the MRI should have been done STAT as ordered”. A review of the facility policy titled, “SCOPE OF SERVICE. Title: Imaging”, dated September 24, 2020, indicated, “SCOPE OF SERVICE...define the Scope of Service...to specify their roles...acting in the best interest of the patient...Preparation of patients for their exams in the Imaging department...Coordinate with nurse provider to arrange the transport of patients to and from Imaging department to complete ordered exams...Use independent judgement and systematic problem solving methods to produce high quality diagnostic information and optimize patient care...Continuity of patient care through different settings...Goals...The Department of Imaging is accountable to the Medical Staff for: The safe delivery of radiological procedures to patients...Trauma ED orders have priority response of 30 minutes. Inpatients STAT orders have a response time of 60 minutes...” A review of the facility policy titled, “POLICY AND PROCEDURE. Title: Code Stroke Activation and Stroke Patient Management,” dated January 23, 2025, indicated, “PURPOSE...To outline the standard of care provided to all patients...Code Stroke Team Members include...ED Staff Nurse caring for the patient...The Code Stroke Team is expected to respond immediately...ROLES AND RESPONSIBILITIES...ED or ICU RN...Accompanies the patient to Imaging...Facilitates the completion of all patient testing...” 3a. On February 12, 2025, at 10:18 a.m., a concurrent interview and record review was conducted with the SCSA. Patient 3’s record indicated Patient 3 was admitted for encephalopathy (a broad range of brain disorders that can affect brain structure, function, or consciousness) and some respiratory symptoms. Past Medical History (PMHX) included ESRD (End Stage Renal Disease, kidneys have permanently lost most of their function and can no longer filter waste products from the blood) SP (status post) Kidney transplant, CVA (Cerebrovascular Accident, stroke, a condition that occur when blood flow to the brain is interrupted) with residual right side deficit, bedridden for the last 3 years. Further record review indicated “Body Systems Assessment” that indicated, pressure injury was identified on January 24, and 25, 2025, as “present on admission” (Unstageable Pressure Injury {PI} to the Left Heel, Unstageable PI to the right ischium {lower and back part of the hip bone}, and Stage 3 PI to the coccyx {tailbone}). The SCSA was unable to provide documented evidence the skin assessment was done initially on admission on January 22, 2025, and no intervention was in place to address the skin breakdown until January 26, 2025, four days after Patient 3’s admission. SCSA stated admission skin assessment is important to identify skin condition when patient is initially admitted to the facility so they can track it throughout their stay and monitor changes and progress. SCSA stated this is also to determine if wound is facility development and to have interventions in place as early as they are identified to prevent development of infection. 3b. On February 12, 2025, at 8:55 a.m., a concurrent interview and record review was conducted with SCSA. Patient 15 was admitted to the facility on December 6, 2024, for Influenza. PMHX included CVA with right hemiplegia (weakness), HTN, chronic bedridden, dysphagia (difficulty in swallowing) s/p PEG Tube (percutaneous endoscopic gastrostomy, placement of a feeding tube through the skin and the stomach wall). Record indicated patient was admitted with pressure ulcers in multiple parts of his body. The SCSA stated there was no documented evidence Patient 15’s skin breakdown was reassessed and photos-documented throughout his stay. SCSA stated weekly photo-documentation was important to document progress of healing or deterioration to determine if treatment was working or needed to be changed. On February 12, 2025, at 9:43 a.m., RN 5 (Wound Care Nurse) was interviewed. RN 5 stated they should have taken a wound photo every week and before the day of discharge according to their policy to monitor progress of the wound, and if treatment needed to be changed. A review of the facility policy and procedure titled, “Pressure Injuries: Assessment, Documentation and Treatment Guidelines,” dated September 26, 2024, indicated, “POLICY...Patients will be assessed for pressure injury...This assessment will create a baseline for further skin and/or wound care, and minimize and/or prevent any further deterioration of tissue...PROCEDURE...Documentation in Medical Record...Photograph and measure all pressure injuries on admission...weekly or completed on admission or discharge...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50122 Based on observation, interview and record review, the facility failed to ensure the facility’s policy and procedures (P&P) were followed for five of 30 sample patients (Patients 16, 17, 22, 23, and 29) when: 1. For Patients 16, 22, and 23, fall risk assessments were not completed; 2. For Patients 17, and 29, no medication reconciliation was completed; 3. For Patient 17, no pain reassessment was completed; and 4. The pediatric crash cart was missing a medication drawer lock. These failures had the potential to jeopardize the health and safety of the patients. Findings: 1a. On February 10, 2025, at 9:05 a.m., a review of Patient 16’s record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ). On February 11, 2025, at 9:07 a.m., a review of the facility document titled, “Face Sheet,” dated February 9, 2025, at 8:22 p.m., indicated Patient 16 was admitted to the facility with a diagnosis of Infectious Enteritis (inflammation of the intestines). On February 11, 2025, at 9:15 a.m., a review of the facility document titled, “History and Physical (H&P),” dated February 9, 2025, at 8:23 p.m., indicated Patient 16 had no previous medical history. On February 11, 2025, at 9:20 a.m., a review of the facility undated document titled, “KINDER I Tool for Emergency Department Falls Risk Assessment,” indicated no documentation in boxes titled, “...Presented to ED [Emergency Department] Because of Falls...Altered Mental Status...Impaired Mobility...Nurse Judgment...” On February 11, 2025, at 9:25 a.m., an interview with the DOQ was conducted. The DOQ stated, “The KINDER I fall assessment should have been completed in full per facility policy...” 1b. On February 11, 2025, at 9:05 a.m., a review of Patient 22’s record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ). On February 11, 2025, at 9:45 a.m., a review of the facility document titled, “Face Sheet,” dated December 27, 2024, at 3:41 p.m., indicated, Patient 22 was admitted to the facility with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease- a condition involving constriction of the airways) exacerbation (sudden worsening). On February 11, 2025, at 9:48 a.m., a review of the facility document titled, “H&P,” dated December 27, 2024, at 3:31 p.m., indicated Patient 22 had a medical history of Hypertension (HTN-elevated blood pressure), and COPD. On February 11, 2025, at 9:50 a.m., a review of Patient 22’s record did not show any record of a KINDER I fall assessment completed by a registered nurse in the emergency room. On February 11, 2025, at 9:55 a.m., an interview with the DOQ was conducted. The DOQ stated, “There was no KINDER I fall assessment completed for Patient 22 while in the emergency room...It should have been completed in the emergency room...” 1c. On February 11, 2025, at 9:05 a.m., a review of Patient 23’s record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ). On February 11, 2025, at 10:02 a.m., a review of the facility document titled, “Face Sheet,” dated January 26, 2025, at 6:05 p.m., indicated Patient 23 was seen in the Emergency room for fever, chills, and body aches. On February 11, 2025, at 10:05 a.m., a review of the facility document titled, “ED Physician Record,” dated January 26, 2025, at 7:13 p.m., indicated, Patient 23 had no previous medical history. On February 11, 2025, at 10:07 a.m., a review of the facility undated document titled, “KINDER I Tool for Emergency Department Falls Risk Assessment,” indicated no documentation in boxes titled, “...Presented to ED Because of Falls...Altered Mental Status...Impaired Mobility...Nurse Judgment...” On February 11, 2025, at 10:10 a.m., an interview with the DOQ was conducted. The DOQ stated, “The KINDER I fall assessment should have been completed in full per facility policy...” On February 11, 2025, at 9:30 a.m., a review of the P&P titled, “Fall Prevention,” dated June 17, 2024, indicated, “...Upon admission, all patients will be assessed for fall risk using an age appropriate, evidence-based tool by a qualified professional...For adult patient in the emergency department, a registered nurse (RN) will use the KINDER I tool...The KINDER I tool will be completed at triage and as warranted by clinical judgement...” 2a. On February 11, 2025, at 9:05 a.m., a review of Patient 17’s record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ). On February 11, 2025, at 10:02 a.m., a review of the facility document titled, “Face Sheet,” dated February 9, 2025, at 10:54 a.m., indicated Patient 17 was admitted to the facility with a diagnosis of a small bowel obstruction (blockage in the small intestine). On February 11, 2025, at 10:07 a.m., a review of the facility document titled, “ED Physician Record,” dated January 26, 2025, at 7:13 p.m., indicated, Patient 17 had a medical history of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior), HTN, and transient ischemic attack (a temporary disruption of blood flow to the brain). On February 11, 2025, at 10:10 a.m., a review of the facility document titled, “Orders,” no date, indicated, “...Reconciliation Status...! Med History...! Admission...” The document further indicated no medication reconciliation history for Patient 17. On February 11, 2025, at 10:15 a.m., an interview with the DOQ was conducted. The DOQ stated, “The medication reconciliation should have been completed by the physician within twenty four hours of admission per policy...the medication reconciliation is the responsibility of the physician...” 2b. On February 11, 2025, at 9:05 a.m., a review of Patient 29’s record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ). On February 11, 2025, at 10:22 a.m., a review of the facility document titled, “Face Sheet,”, dated February 10, 2025, at 11:09 a.m., indicated Patient 29 was admitted to the facility with diagnosis Acute Respiratory Failure.” On February 12, 2025, at 8:45 a.m., a review of the facility document titled, “H&P,” dated February 10, 2025, at 1:39 p.m., indicated Patient 29 had a medical history of HTN, Congestive heart failure (a condition where the heart can’t pump blood efficiently), and Bone cancer. On February 11, 2025, at 10:25 a.m., a review of the facility document titled, “Orders,” no date, indicated, “Reconciliation Status...! Med History...! Admission...” The document further indicated no medication reconciliation history for Patient 29. On February 11, 2025, at 10:28 a.m., an interview with the DOQ was conducted. The DOQ stated, “The medication reconciliation should have been completed by the physician within twenty four hours of admission per policy...the medication reconciliation is the responsibility of the physician...” On February 11, 2025, at 10:30 a.m., a review of the P&P titled, “Medication Reconciliation Across the Continuum of Care,” dated September 24, 2020, indicated, “...It is the policy to reconcile patient’s medication at the time of admission, intradepartmental transfer, and at discharge or transfer to another facility...The admitting/ordering physician compares the home medications list with the medication(s) ordered for treatment during the hospital stay, reconciles the two lists and authenticates the medication order(s) within 24 hours of admission...” 3. On February 11, 2025, at 9:05 a.m., a review of Patient 17’s record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ). On February 11, 2025, at 10:02 a.m., a review of the facility document titled, “Face Sheet,” dated February 9, 2025, at 10:54 a.m., indicated Patient 17 was admitted to the facility with a diagnosis of a small bowel obstruction (blockage in the small intestine). On February 11, 2025, at 10:07 a.m., a review of the facility document titled, “ED Physician Record,” dated January 26, 2025, at 7:13 p.m., indicated, Patient 17 had a medical history of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior), HTN, and transient ischemic attack (a temporary disruption of blood flow to the brain). On February 11, 2025, at 10:10 a.m., a review of the facility document titled, “Orders,” dated February 9, 2025, at 11:02 p.m., indicated, Patient 17 had an order for “...Morphine...Order Details: 2 mg [milligrams]...IV [intravenous-in the vein] Push...q4H [every four hours]...PRN [as needed]...Pain 7-10...” On February 11, 2025, at 10:20 a.m., a review of the facility document titled, “Medication Administration Record,” dated February 10, 2025, at 3:54 p.m., indicated morphine 2 mg IV was administered by Registered Nurse (RN) 1. On February 11, 2025, at 10:15 a.m., a review of the facility document titled, “Pain Assessment,” dated February 10, 2025, at 3:15 p.m., indicated pain level of 6/10. The document further indicated pain reassessment was completed on February 10, 2025, at 6:38 p.m., with a pain level of 0/10. On February 12, 2025, 11:10 a.m., an interview of the DOQ was conducted. The DOQ stated, “...PRN pain reassessment should have been completed within 60 minutes after administration...” On February 12, 2025, at 11:20 a.m., a review of the P&P titled, “Medication Ordering and Administration,” dated December 16, 2022, indicated, “...Administered PRN medications must be documented in the medical record along with the indication for administration and patient response. Assessment of patient response to the medication must occur within one hour following the administration...” 4. On February 10, 2025, at 9:08 a.m., a tour of the emergency room was conducted with Director of Women’s Services (DWS), Interim Director of Patient Experience (IDPE) and the Director of Emergency Room (DER). On February 10, 2025, at 9:25 a.m., during the tour of the ED, the Pediatric crash cart was observed with no red lock on the top drawer which contained emergency medications. On February 10, 2025, at 9:30 a.m., a review of the facility document titled, “Code Cart Checklist (Pediatric),” was conducted with the DER. The document indicated, “...Month/Year...February...2025...Unit...ED...Day...10...Lock#[number]...13899304...Signature...[unknown signature]...Action Required...” There was no documentation under “...Action required...” indicating any action was taken to replace missing lock on medication drawer. On February 10, 2025, at 9:35 a.m., an interview with the DER was conducted. The DER stated the lock was missing on the pediatric crash cart. On February 11, 2025, at 3 p.m., an interview with the DOQ was conducted. The DOQ stated, “...The Emergency room staff should have notified pharmacy to replace the lock. The drawer ideally would get a new lock placed on the crash cart...” On February 11, 2025, at 3:30 p.m., a review of the facility P&P titled, “Emergency Drugs/Supplies,” dated December 16, 2022, indicated, “...Emergency medications must be checked by a pharmacist before the cart is sealed...Code Cart trays will be placed into the medication drawers of the carts...a pharmacist will affix a plastic tamperproof lock ensuring that the Code Cart is complete and secure...Department, units and users will notify pharmacy when...The container is opened or the seal is broken...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to ensure Patient 22 received and signed for, “Condition of Admission/Registration, Treatment Authorization and Financial Responsibility,” (form that establishes the conditions under which a patient is admitted for inpatient services) when he was hospitalized on November 6, 2024, through November 12, 2024. This failure had the potential for Patient 22 to not understand his rights as an inpatient, and may fail to exercise his rights during hospitalization. Findings: On November 13, 2024, at 3:30 p.m., the Patient Access Services Manager (PASM) was interviewed regarding “Condition of Admission (COA),” for Patient 22. PASM stated the COA was not done. The document presented indicated the facility had attempted to complete the COA the day Patient 22 was discharged home. On November 14, 2024, at 2:05 p.m., the PASM was interviewed. PASM stated COA is important and should have been done at the time of patient registration. PASM stated they have no COA policy, and they are currently using the California Hospital Association Manual (CHAM) for guidelines. On November 14, 2024, at 2:25 p.m., Risk Manager (RM) was interviewed. RM stated COA is important so the patient can be made aware of their “Rights”. RM stated patients are supposed to be provided with information they can understand, information on how to file a grievance, and it should had been done upon admission and registration. A review of the facility document titled, “Conditions of Admission/Registration, Treatment Authorization and Financial Responsibility”, dated April 2022, indicated, “...As the individual who will be receiving services...Patient’s Bill of Rights and Patient’s Responsibilities...carefully read and fully understand this Agreement and receive a copy for my records...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for six of 30 sample patients (Patient 3, 7, 14, 16, 19, and 21), when: 1. For Patients 3, 16, and 21, pain assessment was not completed before and after pain medication administration. 2. For Patients 7, 14, and 19, the medication reconciliation was not completed when admitted. These failures had the potential to compromise patient safety, result in inadequate pain management, and medication discrepancies that could have led to medication errors. Findings: 1a. A review of Patient 3’s record was conducted on November 12, 2024, at 10:02 a.m., with the Risk Manager (RM). A facility document titled, “ED (Emergency Department) Physician Record,” dated November 11, 2024, at 9:05 p.m., was reviewed and indicated Patient 3 was admitted to the facility on November 11, 2024, for suicidal attempt (an act in which an individual tries to kill themselves but survives). A facility document titled, “Medication Administration Record,” dated November 12, 2024, was reviewed. The document indicated, “...hydrocodone-acetaminophen (Norco 10 mg-325 mg [a unit of measurement] oral tablet [by mouth] [pain medication]...1Tabs [Tablets], Tab [Tablet], oral, q4H PRN [every four hours as needed] pain 7 -10 [a pain scale measuring 10 as highest level of pain and zero the lowest] (Severe)...” A facility document titled, “Med [Medication] Admin [Administration]- PRN [as needed],” was reviewed. On November 12, 2024, at 10:29 p.m., Norco 10 mg -325 mg Tylenol was administered and the patient’s pain level prior to the administration was 7/10. Pain level was not reassessed after pain medication was given. There was no documented evidence pain assessment was conducted after Norco was administered on November 12, 2024. An interview was conducted on November 12, 2024, at 2 p.m., with the (RM). The RM verified pain reassessment was not conducted on November 12, 2024, after Norco was administered to Patient 3. The RM stated the pain level should have been reassessed after medication administration. The RM stated this was not done for Patient 3, the policy was not followed. 1b. A review of Patient 16’s record was conducted on November 14, 2024, at 9:20 a.m., with the Quality Improvement Analyst (QIA). A facility document titled, “History and Physical (H&P),” dated November 12, 2024, at 8:18 a.m., was reviewed and indicated Patient 16 was admitted to the facility on November 11, 2024, for respiratory failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood), pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus) and generalized weakness (a feeling of decreased muscle strength in most parts of the body). An untitled facility document was reviewed on November 12, 2024, at 8:34 a.m., and indicated Patient 16’s pain level was acute, there was no indication of a numerical scale rating of pain. A facility document titled, “Med Admin - PRN,” was reviewed. On November 12, 2024, at 8:34 a.m., Norco 5 mg-325 mg Tylenol was administered and Patient 16’s pain level prior to the administration was not documented. Pain level was not assessed prior to pain medication administration and not reassessed after pain medication was given to Patient 16. An interview was conducted on November 12, 2024, at 9:20 a.m., with the QIA. The QIA stated pain level was not assessed on November 12, 2024, at 8:34 a.m. The QIA stated pain level should have been assessed prior to medication administration and reassessed after pain medication was given, the policy was not followed. There was no documented evidence pain assessment was conducted on November 12, 2024, prior to pain medication administration and reassessment of efficacy of pain medication administered to Patient 16. 1c. A review of Patient 21’s record was conducted on November 13, 2024, with the Senior Clinical System Analyst (SCSA). The facility document “History and Physical,” indicated Patient 21 was admitted to the hospital on November 5, 2024, for right knee pain status post (S/P) fall with injury, comminuted displaced tibial plateau fracture (severe knee injury requiring surgical intervention to realign and fix the fractured pieces using plates and screws). A facility document titled, “Medication Administration Record (MAR),” was reviewed and indicated, “...HYDROmorphone (Dilaudid- pain medication) 1 mg IV Push (administered intravenously) q4H interval, PRN for Pain 7-10, administer over two minutes...” On November 13, 2024, at 9:30 a.m., a concurrent interview and record review of the MAR dated November 6, 2024, at 5:46 p.m., was conducted with the SCSA. The MAR record indicated Patient 21 received HYDROmorphone 1 mg IV Push for complaint made for pain 9/10 scale. There was no documented evidence pain reassessment was conducted after HYDROmorphone was administered on November 6, 2024. SCSA stated pain reassessment should have been done an hour after patient was pain medicated to check if intervention was effective. SCSA further explained, it is generally a standard to conduct pain reassessment after pain medication was administered. A review of the facility’s P&P titled, “Assessment/Reassessment of Patient,” revised June 2024, was conducted. The P&P indicated, “...Pain...Reassess and document efficacy...” 2a. A review of Patient 7’s record was conducted on November 14, 2024, at 9:40 a.m., with the RM. A facility’s document titled, “H&P,” dated November 12, 2024, was reviewed. The document indicated Patient 7 was admitted to the facility on November 13, 2024, for back pain. A facility document titled, “Medication History,” dated November 11, 2024, was reviewed. The documents indicated Patient 7’s medication reconciliation was not completed on admission. A concurrent interview and record review were conducted on November 14, 2024, at 10:40 a.m., with the RM. RM stated the admitting physician is responsible for medication reconciliation once the patient is admitted. The RM stated the medication reconciliation was not completed by the physician on admission for Patient 7. A concurrent interview and record review were conducted on November 14, 2024, at 2 p.m., with Physician 3. Physician 3 stated it is usually the admitting doctor who completes the medication reconciliation, this medication reconciliation was not completed. 2b. A review of Patient 14’s record was conducted on November 13, 2024, at 3:10 p.m., with the Manager of Nursing Administration (MNA). A facility document titled, “H&P,” dated November 7, 2024, at 10:09 a.m., was reviewed. The document indicated Patient 14 was admitted to the facility on November 7, 2024, for uncontrolled bilateral leg pain (pain not controlled on both legs of the body). A facility document titled, “Medication History,” dated November 6, 2024, was reviewed. The documents indicated Patient 14’s medication reconciliation was not completed on admission. A concurrent interview and record review were conducted on November 14, 2024, at 1:42 p.m., with Physician 1. Physician 1 stated, “...medication reconciliation’s are done prior to admission...if the medication reconciliation is not done within 48 hours, they are notified...” 2c. A review of Patient 19’s record was conducted on November 14, 2024, at 10:10 a.m., with the MNA. A facility document titled, “H&P,” dated November 11, 2024, at 7:11 p.m., was reviewed. The document indicated, Patient 19 was admitted to the facility on November 9, 2024, for seizure (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness). A facility document titled, “Medication History,” undated, was reviewed. The document indicated Patient 14’s medication reconciliation was not completed on admission. A concurrent interview and record review were conducted on November 14, 2024, at 1:44 p.m., with Physician 2. Physician 2 stated, “...medication reconciliation’s are done prior to admission...for Patient 19 the medication reconciliation was not completed, the physician assistant should have done it...” A concurrent interview and record review were conducted on November 14, 2024, at 2:25 p.m., with the DOP. The DOP stated the medication reconciliation was not completed for Patients 7, 14, and 19 at admission. The DOP further stated the admitting provider is responsible for completion. If a Physician Assistant or Nurse Practitioner does not complete the medication reconciliation, it is ultimately the responsibility of the admitting physician per policy. A review of the facility’s P&P titled, “Medication Reconciliation Across the Continuum of Care,” dated September 26, 2024, was conducted. The P&P indicated, “...The policy applies to the medical staff, nursing staff, allied professionals including, but not limited to...and all who may be involved in the medication reconciliation process...It is the policy to reconcile patient’s medications at the time of admission, intradepartmental transfer, and at discharge or transfer to another facility. The completed list of medications is provided to the next caregiver upon transfer within the facility. The completed medication list is provided to the patient at the time of discharge...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45431 The facility failed to ensure the patients’ care were provided in a safe environment, for nine of 21 sampled patients (Patients 3, 4, 6, 11, 13, 16, 17, 19, and 21), when: 1. For Patient 3, who was on a 5150 hold (an involuntary hold for 72 hours), was found in the bathroom unresponsive and unsupervised with a cord tied around his neck. This failure resulted in Patient 3’s eventual death (Refer to A-0144); 2. For Patient 6, assessments were not conducted while the patient was in restraints, in accordance with the facility’s policy and procedure. This failure had the potential to place the patient at an increased risk of serious injury (Refer to A-0179); and 3. Consents for the Conditions of Admissions were not completed for eight of 21 sampled patients (Patients 4, 6, 11, 13, 16, 17, 19, and 21). These failures posed the increased risk for the patients to not be informed of their rights as the patients receiving care in the hospital (Refer to A-0116). The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the patients’ rights were protected.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 44871 Based on interview and record review, the hospital failed to ensure the consents for the Conditions of Admissions were completed, for eight out of 21 sampled patients (Patients 4, 6, 11, 13, 16, 17, 19, and 21), in accordance with the facility’s policy and procedure. These failures posed the increased risk for the patients to not be informed of their rights as the patients receiving care in the hospital. Findings: On January 23, 2024, an unannounced visit was conducted at the facility for a complaint validation survey. On January 24, 2024, at 10:40 a.m., a review of the medical records of Patients 4, 6, 11, 13, 16, 17, 19, and 21, was conducted with the Director of Patient Access Services (DPAS). The records indicated the following: - For Patient 4, the facility’s document titled, “Face Sheet,” dated January 2, 2024, indicated, “...Admitting Information, ADM [admit] DATE 01/02/2024 [January 2, 2024], TIME 0317 [3:17 a.m.]...ADM DIAGNOSIS ACUTE RESPIRATORY FAILURE [inefficient breathing]...” The facility’s document titled, “Conditions of Admission/Registration Treatment Authorization and Financial Responsibility,” dated January 2, 2024, indicated, “...MUATS [medically unable to sign]...” - For Patient 6, the facility’s document titled, “Face Sheet,” dated January 15, 2024, was reviewed. The document indicated, “...Admitting Information, ADM [admit] DATE 01/15/2024 [January 15, 2024], TIME 0458 [4:58 a.m.]...ADM DIAGNOSIS SEVERE SEPSIS [a life-threatening infection in the blood]...” The facility’s document titled, “Conditions of Admission/Registration Treatment Authorization and Financial Responsibility,” dated January 15, 2024, indicated, “...pt [Patient 6] unable to sig [sic]...” - For Patient 11, the facility’s document titled, “Face Sheet,” dated January 8, 2024, was reviewed. The document indicated, “...Admitting Information, ADM DATE 01/08/2024 [January 8, 2024], TIME 2356 [11:56 p.m.]...ADM DIAGNOSIS ALTERED SENSORIUM [confusion]...” The facility’s document titled, “Conditions of Admission/Registration Treatment Authorization and Financial Responsibility,” dated January 8, 2024, indicated, “...RELATIONSHIP IF NOT PATIENT SIGNATURE ... GARCSH [registration staff initials ]...” - For Patient 13, the facility’s document titled, “Face Sheet,” dated January 20, 2024, was reviewed. The document indicated, “...Admitting Information, ADM DATE 01/20/2024 [January 20, 2024], TIME 2155 [9:55 p.m.]...ADM DIAGNOSIS CELLULITIS [infection of skin] OF ARM, LEFT...” The facility’s document titled, “Conditions of Admission/Registration Treatment Authorization and Financial Responsibility,” dated January 20, 2024, indicated, “ ...PT [Patient 13] UATS [unable to sign] ...” - For Patient 16, the facility’s document titled, “Face Sheet,” dated January 22, 2024, was reviewed. The document indicated, “...Admitting Information, ADM DATE 01/22/2024 [January 22, 2024], TIME 1529 [3:29 p.m.]...ADM DIAGNOSIS UTI [urinary tract infection]...” The facility’s document titled, “Conditions of Admission/Registration Treatment Authorization and Financial Responsibility,” dated January 20, 2024, indicated, “...VERBAL AUTH [authorization] REQUESTED-WEAKNESS...” - For Patient 17, the facility’s document titled, “Face Sheet,” dated January 20, 2024, was reviewed. The document indicated, “...Admitting Information, ADM DATE 01/20/2024 [January 20, 2024], TIME 1119 [11:19 a.m.]...ADM DIAGNOSIS SEIZURE LIKE ACTIVITY...” The facility’s document titled, “Conditions of Admission/Registration Treatment Authorization and Financial Responsibility,” dated January 20, 2024, indicated, “ ...PT [Patient 17] MEDICALLY UNABLE TO SIGN ...” - For Patient 19, the facility’s document titled, “Face Sheet,” dated January 20, 2024, was reviewed. The document indicated for Patient 19, “...Admitting Information, ADM DATE 01/20/2024 [January 20, 2024], TIME 0041 [12:41 a.m.]...ADM DIAGNOSIS SOCIAL PROBLEM...” The facility’s document titled, “Conditions of Admission/Registration Treatment Authorization and Financial Responsibility,” dated January 19, 2024, indicated, “ ...PT [Patient 19] UATS [unable to sign] ...” - For Patient 21, the facility’s document titled, “Face Sheet,” dated January 12, 2024, was reviewed. The document indicated, “...Admitting Information, ADM DATE 01/12/2024 [January 12, 2024], TIME 0316 [3:16 a.m.]...ADM DIAGNOSIS ALTERED MENTAL STATE...” The facility’s document titled, “Conditions of Admission/Registration Treatment Authorization and Financial Responsibility,” dated January 11, 2024, indicated, “...no interview pt [Patient 21] unresponsive...” There was no documented evidence the patient/authorized legal representatives’ signed the form “Condition of Admission/Registration Treatment Authorization and Financial Responsibility.” There was no documented evidence of the reason why the patients’ or the patients’ legal representatives’ signatures were not obtained for Patients 4, 6, 11, 13, 16, 17, 19, and 21. An interview and record review were conducted with the DPAS on January 24, 2024, at 10:48 a.m. The DPAS stated the Condition of Admission/Registration Treatment Authorization and Financial Responsibility forms for the above patients were incomplete and were filled out incorrectly per the facility’s policy. The DPAS further stated if the patient is unable to sign, then a legally authorized representative will sign if available, and if that person is not available then two registration personnel will sign and date the form per the facility’s policy. A review of the policy and procedure (P&P) titled, “Consents,” dated April 28, 2022, was conducted. The P&P indicated, “...Every competent adult person has the fundamental right of self-determination over his orher [sic] person and property. Individuals unable to exercise this right, such as minors and incompetent adults, have the right to be represented by another who will protect their interests and preserve their basic rights. The hospital may not permit any treatment unless the patient, or legally authorized representative has consented to the treatment, unless emergency consent applies...Incompetent Adult Patients Not Under a Conservatorship...The patient’s closest available relative/designated decision-maker has given consent. The Bioethics Committee may be convened to assist in identifying a decision-maker. This is an individual who has an understanding of the patient’s current wishes and acts in the patient’s best interest regardless of marital status or a familiar relationship...In the event that the patient cannot write a legible signature, the patient’s mark must be obtained. The hospital representative should write the patient’s name in full. The patient should place his X beneath his name. Two persons must witness the patient placing his mark on the form...Consent by Other Means The responsible physician or designee shall discuss the patient’s condition and the recommended treatment with patient’s legal representative for health care treatment. Telephone Consent...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45431 Based on observation, interview, and record review, the facility failed to ensure a safe environment was provided for one patient (Patient 3), when Patient 3, who was on a 5150 hold (an involuntary hold for 72 hours), was found in the bathroom unresponsive and unsupervised with a cord tied around his neck. This failure resulted in Patient 3’s eventual death. Findings: A tour of the Intensive Care Unit (ICU, unit for critically ill patients) was conducted on January 23, 2024, at 9:54 a.m., with the Chief Nurse Officer (CNO) and ICU Manager (ICUM). During an observation on January 23, 2024, at 10:26 a.m., in Patient 3’s room, Patient 3 was observed to be unresponsive when Sitter1 called Patient 3’s name and when she tried to stimulate him to wake up. A very faint ligature mark was observed on Patient 3’s neck. During an interview on January 23, 2024, at 10:34 am, conducted with Patient 3’s family member (FM 1), FM 1 stated he came the next day and informed the staff that he believed the motor vehicle accident was not an accident but a suicide attempt. FM 1 stated Patient 3’s behavior changed after a loss of a family member two years ago to cancer. The FM stated they noticed Patient 3 was more depressed and had sought help for it multiple times. On January 24, 2024, at 10:30 a.m., a review of Patient 3’s record was conducted with Emergency Department Manager (EDM). A review of the facility document titled, “History and Physical,” dated January 7, 2024, indicated Patient 3 was admitted on January 7, 2024, with a diagnosis of encephalopathy (a brain disease that alters brain function or structure). A review of an undated facility document titled, “Diagnoses,” indicated, “...Diagnosis: Depression with Anxiety ...Diagnosis date: 01/08/2024 [January 8, 2024]...” A review of Patient 3’s physician’s order, dated January 8, 2024, written at 4:59 p.m., indicated, “...Suicide Precaution ...Now...” A review of Patient 3’s physician’s order, dated January 8, 2024, written at 7:07 p.m., indicated, “...Ongoing Suicide Assessment...routine BID [two times a day]...order comment: placed by dicern expert [software program] based on documentation of Suicide Risk [Name of tool] Assessment...” A review of facility document titled, “Physician Progress Note,” dated January 10, 2024, indicated, “ ...Assessment/Plan...Bipolar, acute mixed episode with psychotic features...reconsulted psychiatry...given patient has continued experience paranoia and has tried to escape hospital...” A review of facility document titled, “Psychiatry Consult Notes,” dated January 10, 2024, indicated, “...Chief Complaint: “I just had an urge to run.” Reason for Consultation: determine psychiatric disposition, patient is medically cleared. Subjective...Staff report patient continues to show paranoia with impulsive behaviors. Code Grey called last evening as patient suddenly bolted out of the room. He made it to the emergency room lobby...Transfer, discharge, and level of care: Patient’s psychiatric condition has not continued to improve. Although he retains good insight, his mania and psychosis is progressing and he meets 5150 hold criteria for grave disability and danger to self...” A review of facility’s document titled, “ History and Physical,” dated January 11, 2024, indicated, “...7:10 pm 1/11 [January 11, 2024] code blue [unexpected cardiac or respiratory arrest requiring resuscitation] called pt [patient] found attempting to hang self in bathroom with call light cord around his neck. Pt [patient] went into PEA [Pulseless Electrical Activity, a type of irregular heart rhythm] arrest...received CPR [Cardiopulmonary Resuscitation, procedures to attempt to resuscitate] for 5 [five]-10 [ten] min [minutes]...He was intubated [insertion of a tube in the airway to assist in breathing] successfully during CPR...pt [Patient 3] moved to ICU...” A review of the transportation service untitled document, dated January 11, 2024, indicated, “...Crew obtained a report on pt [patient] before entering the pt [patient] room around 1857h [6:57 p.m.]. EMT [Emergency Medical Technician, Name of ambulance staff] was obtaining the last bit of the report and signature from RN [registered nurse] when EMT [Name of ambulance staff] walked into the pt [patient] room. EMT [Name of ambulance staff] found two family members at the bedside. They told her the pt [patient] was using the restroom since it was a long drive...the family notified him [RN] that the patient was in the restroom. RN knocked but no answer came...RN opened the door and when EMT [Name of ambulance staff] saw the pts [patient’s] legs she ordered the family to leave immediately...The RN pulled the pt out from the toilet and the wall...and called a code blue...” A review of facility record titled, “Cardiopulmonary Resuscitation Record,” dated January 11, 2024, indicated, “ ...Event recognized date: 01/11/2024 [January 11, 2024], Time: 1907 [7:07 p.m.]... witnessed arrest...1908h [7:08 p.m.] breathing assisted...no BP (blood pressure)...Rhythm...PEA...1921h [7:21 p.m.] Reason Resuscitation ended- Survived...1923 [7:23 p.m.] transferred to ICU...” A review of facility document titled, “Discharge Summary,” dated January 25, 2024, indicated Patient was unresponsive overnight and time of death was declared at 1:30 a.m. on January 25, 2024. There was no documented evidence the “Environmental Rounds to Secure Rooms (Including Bathrooms) for Suicidal Patients form” was completed on January 10, 2024. There was no documented evidence a suicide risk assessment was conducted for Patient 3 from January 9, 2024, through January 18, 2024. During an interview on January 24, 2024, at 1:36 p.m., conducted with RN 1, RN1 stated he did not document a suicide risk assessment even after he was informed of Patient 3’s 5150 hold. RN 1 stated he did not know who was watching Patient 3 during the time he was giving report to Transportation Staff 1. RN 1 further stated he allowed the sitter to leave the room because he assumed Transport Staff 2, who was in the room, was watching Patient 3. During a concurrent interview and record review on January 24, 2024, at 1:42 p.m, conducted with RN 1, the “Environmental Rounds to Secure Rooms (Including Bathrooms) for Suicidal Patients form,” dated January 11, 2024, completed by Sitter 3 at 6 a.m., was reviewed. The document indicated, “...Things to be checked...Room is free from hanging or strangulation hazard...call bell cord...Yes box marked...” RN 1 stated the bathroom cord used by Patient 3 on his suicide attempt was not removed because RN 1 did not know how to remove it. During an interview on January 25, 2024, at 9:57 a.m., conducted with FM 2, FM 2 stated when RN 1 was giving report and the sitter left the room, Patient 3 got out of bed and went to the bathroom. FM 2 stated no staff were watching or supervising Patient 3 while he was in the bathroom. FM 2 further stated she notified RN 1 when she noticed Patient 3 was in the bathroom for too long. During an interview on January 25, 2024, at 11:01 p.m., conducted with House Supervisor (HS), the HS stated she was notified by the case manager that a 5150 evaluation was needed for Patient 3. The HS stated, after her evaluation of Patient 3, she deemed Patient 3 as a danger to self and issued the 5150 hold. During an interview on January 25, 2024, at 1 p.m., conducted with Sitter 2, Sitter 2 stated she was not assigned as a sitter for Patient 3, however, she volunteered to sit with Patient 3 until he was discharged. Sitter 2 stated she left the room for a few minutes and when she returned Patient 3 was in the bathroom. She further stated she was not watching Patient 3 while he was in the bathroom nor was she aware that he was on a 5150 hold. During an interview on January 25, 2024, at 3 p.m., conducted with Sitter 3, Sitter 3 stated she left when the incident happened, however, she mentioned to RN 1 that Patient 3 was going to the bathroom more frequently than normal that day. A review of the policy and procedure (P&P) titled, “Identification and Management of Patients At Risk for Suicide,” dated April 14, 2023, indicated, “...Purpose: The purpose of this policy is to outline the requirements for ensuring the safety of patients with actual or potential thoughts of self-harm or suicide...It is the policy of [Name of facility] to identify and assess patient at risk for suicide. Suicide Risk screening will be conducted on all patients entering the facility...Procedure...Screening and Assessment for Suicidal Ideation...Depression, hopelessness, or sadness during the past month...Patient environment....Prior to placing a patient in any non-designated area who is assessed as at risk for suicide, staff shall conduct and document a safety risk assessment of the patient environment and identify features and objects that could be used by the patient for self-harm...Observation...For patient assessed as moderate or high risk for suicide, maintain continuous observation during patient’s use of bathroom...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 42512 Based on interview and record review, the hospital failed to ensure assessments were conducted on a patient on restraints, for one of 21 sampled patients (Patient 6), in accordance with the facility’s policy and procedure. This failure had the potential to place the patient at an increased risk of serious injury. Findings: A review of Patient 16’s record was conducted on January 25, 2024. The “History and Physical,” dated January 22, 2024, indicated Patient 16 was admitted to the facility on January 22, 2024, with diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities). The document titled, “Physician Orders for Restraint Use,” indicated soft wrist restraints was ordered for Patient 16 on January 22, 2024, at 12:29 p.m., through January 23, 2024, at 5:42 p.m. There was no documented evidence the patient’s restraint use was assessed every four hours on January 23, 2024, between 4:01 a.m. and 5:59 p.m. An interview and record review was conducted with Unit Manager (UM) 1 on January 25, 2024, at 9:20 a.m. UM 1 stated there was no documentation which indicated Patient 16 was assessed every four hours on January 23, 2024. UM 1 stated the facility’s policy and procedure was not followed. She further stated the registered nurse should have documented Patient 16’s restraints at 8:00 a.m., 12 p.m., and at 4:00 p.m., on January 23, 2024. A review of the facility’s policy and procedure titled, “Restraints,” indicated, “...To provide guidance for the use and management of restraints...The assessment is documented in the patient’s record...Documentation of monitoring is expected to occur a minimum of every 4 [four] hours...Episodes of restraint shall be documented as indicated on currently approved assessments, monitoring and ordering forms and computer screens and may include skin integrity, hygiene, nutrition, elimination, circulation, vital signs, and reaction to restraints...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42512 Based on interview and record review, the hospital failed to ensure assessments were conducted on a patient on restraints, for one of 21 sampled patients (Patient 6), in accordance with the facility’s policy and procedure. This failure placed the patient at an increased risk of serious injury. Findings: A review of Patient 16’s record was conducted on January 25, 2024. The “History and Physical,” dated January 22, 2024, indicated Patient 16 was admitted to the facility on January 22, 2024, with diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities). The document titled, “Physician Orders for Restraint Use,” indicated soft wrist restraint was ordered for Patient 16 on January 22, 2024, at 12:29 p.m., through January 23, 2024, at 5:42 p.m. There was no documented evidence the patient’s restraint use was assessed every four hours on January 23, 2024, between 4:01 a.m. and 17:59 p.m. An interview and record review was conducted with Unit Manager (UM) 1 on January 25, 2024, at 9:20 a.m. UM 1 stated there was no documentation which indicated Patient 16 was assessed every four hours on January 23, 2024. UM 1 stated the facility’s policy and procedure was not followed. She further stated the registered nurse should have documented Patient 16’s restraints at 8 a.m., 12 p.m., and at 4 p.m., on January 23, 2024. A review of the facility’s policy and procedure titled, “Restraints,” indicated, “...To provide guidance for the use and management of restraints...The assessment is documented in the patient’s record...Documentation of monitoring is expected to occur a minimum of every 4 [four] hours...Episodes of restraint shall be documented as indicated on currently approved assessments, monitoring and ordering forms and computer screens and may include skin integrity, hygiene, nutrition, elimination, circulation, vital signs, and reaction to restraints...””